PMDC Community PDF

SECTION 8: COMMUNITY MEDICINE
Written by:
Dr. Rana Faizan Ali
M.B.B.S (Dali University, Yunnan, P.R China)
PM&DC (I,II,III)

Note: This section is not yet revised by anyone. Excuse me for some spelling
mistakes.

Community Medicine Curriculum given by PMDC for Step 1:
I. Food & Nutrition 1 SEQ
2. Control and prevention of non-communicable and communicable diseases 1 SEQ
3. MCH/Reproductive Health/STI 1 SEQ

Division of Marks: Total 30 Marks
3 SEQ = 15 Marks (5 marks for each SEQ)
15 MCQs = 15 Marks (1 mark for each MCQ)

Community Medicine SEQs asked in Last 4 PMDC Papers:
dr.rfa89@gmail.com
Q1: Classify Food? What are macronutrients and micronutrients?
Q2: How you can prevent and control Epidemic?
Q3: Prevention of Mother - Child transmission of HIV?
----------------------------------------------------------------------
Q1: Water borne diseases, their prevention and control?
Q2: What is sterilization and disinfection? Name some disinfectants.
Q3: Write the names of STDs. how will you prevent it in a community?
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Q1: What are the Principles of Integrated Child Care? [5]
Q2: Communicable Diseases:
a. Mode of Transmission of: [2.5]
i. Filariasis ii. Dengue iii. Enterobiasis
b. Prevention of: [2.5]
i. Scabies ii. Teniasis iii. Rabies
Q3: Nutrition:
a. How will you do Nutritional Assessment of General Population? [2.5]
b. How will you do Nutritional Assessment of Child/Child under 5 years age? [2.5]
--------------------------------------------------------------------------
Q: Protein energy malnutrition prevention under 5 years,
Q: IHD risk factors and their Prevention.

COMMUNITY MEDICINE
According to WHO: A system of delivery of comprehensive health care to the
individual or family at the level of community by a health team in order to
promote physical, mental and social wellbeing.

Aims & Objective of Community Medicine:
-To provide skill, knowledge, attitude to the students, concerning delivery of
comprehensive healthcare.
-To bring whole spectrum of health services to all segments of community.
-Being expert, how to carry out immunization.
-Ability to identify noticeable health problems and disease.
-To know sign/symptoms of common diseases for diagnosis and treatment.
-Knowledge on public health administration
-To acquired clinical skill at all levels for diagnosis, screening, referral . Treatment
and follow up.

Importance of Community Medicine:
It has involvement with:-
-Public needs and demand
-Treads of diseases
-Nature of diseases
-Regional ecology
-National policy
-International agreement.

Community Participation:
The process by which individual and families assumes responsibility for their own
health and welfare and for those of the community and develop the capacity to
contribute their and the communitys development.
Benefits of community participation:
-It leads to a sense of responsibility for the project.
-More will be accomplished.
-Participation guarantees that a felt need is involved.
-Services can be provided at a lower cost.
-Participation has an intrinsic value for participants.
-It is catalyst for further development effort.
-Participation ensures everything is done in the right way.
-Use indigenous knowledge and expertise.
-Freedom from dependence on professionals.

Health Care of the Community:
According to the World Health Organization, health care embraces -
All the goods and services designed to promote, maintain, monitor or restore
health, including preventive, curative and palliative interventions, whether
directed to individuals or to populations.
It is not limited to medical care.

Providers: A health care provider could be a government institution such as a
hospital or medical laboratory, physicians, support staff, nurses, therapists,
psychologists, veterinarians, dentists, pharmacists or even a health insurance
company.
Characteristic of health care:
-Appropriateness-services is needed in relation to essential human needs,
priorities and policies.
-Comprehensiveness- there is optimum mix of preventive, curative and
promotional services.
-Adequacy-i.e. service is proportional to requirement.
-Availability-i.e. ratio between population of administrative unit and the health
facility.
-Accessibility-i.e.it may b geographical, economical or cultural accessibility.
-Affordability- i.e. the cost of health care should be within the means of the
individual and the state.
-Feasibility-i.e. operational efficiency of certain procedures and material
recourses.

Food & Nutrition
Food is a composite mixture of substances, which when consumed perform
certain function in the body.
Constitute of food are:-
-Protein
-Fat
-Carbohydrates
-Vitamins
-Minerals
-Water

Functions of food:-
-Energy yielding.
-Helps to building and maintaining the body.
-Protects the body from various types of diseases.
-Regulates the tissue function.

Classification of foods:-
1. According to origin: a. plant origin
b. animal origin
2. According to chemical composition:-
a. Protein b. fat c. carbohydrate
d. Vitamins e. minerals
3. According to function:-
a. energy yielding food-rich in carbohydrate.
b. body building food-rich in protein.
c. protective food-rich in protein, vitamins and minerals.
Nutrition: is the process by which, living organism utilize food for maintenance of
life, growth, the normal functioning of tissue and organ, and production of
energy.
Nutrients are the constituents in food, that must be supplied to the body in
suitable amounts.
Nutrients may be:-
1. Macro-nutrients:-they form main bulk of food. They are protein, fat,
carbohydrate.
2. Micro-nutrients:-They are required in small amount. They are vitamins and
minerals.

Protein:
Proteins are complex organic compounds, composed of carbon, hydrogen,
oxygen, nitrogen and sulphur in varying amount.
Amino acids:-Protein are made up of simpler substances which are the building
blocks of protein , called amino acids.
Essential amino acids
Non-essential amino acids

Sources of protein:-
1. Animal source-egg, fish, meat, milk
2. Plant source- pulses, nuts, beans.

Types of protein:-
1. First class protein:-protein that provide all the essential amino acids needed for
body. e.g. protein of animal sources.
2. Second class protein:-protein that lacks one or more essential amino acids. E.g.
protein of plant sources

Function of protein:-
1. Building of new cell and maintain or repair of injured cell.
2. Provide energy 4 kcal/gm.
3. Takes part in defense mechanism of body.
4. Helps to synthesize antibody, enzymes, hormones.

Daily requirement of protein:-
Adults-1gm/kg body weight.
Pregnancy- +14gm.
Lactation- +25gm

Effects of protein deficiency:-
1. During pregnancy:- still birth,
premature birth,
anemia.
2. Infancy and early childhood:- kwashiorkor
marasmus
mental retardation
3. Adults :- loss of weight
under weight
poor musculature
delay wound healing.

Fats/lipid:
Fats are composed of fatty acids, triacylglycerol, phospholipids, glycolipids etc.
Classification:-
-Simple lipids triglycerides.
-Compound lipid phospholipids.
-Derived lipids-cholesterol.
-Most of body fat(99%) in the adipose tissue are triglycerides.
-Human body can synthesis triglycerides and cholesterol endogenously.
-Liver plays a central role in bodys cholesterol balance.

Sources of fats:-
1. Animal sources:-ghee, butter, milk, cheese, eggs, fats of meat and fish.
2. Vegetable sources:-seeds of groundnut, mustard, sesame, coconut etc.
Daily requirement of fat:- 10-20gm
Functions of fat:-
1. Supply energy (9 kcal/gm).
2. Supply essential fatty acids.
3. Carries fat soluble vitamins-A, D, E & K.
4. Stimulates the secretion of bile, hormones.
5. Helps formation of cell membrane.
6. Gives support to viscera.
7. Protect body from cold and acts as insulator.
Disease due to fats:-
obesity,
coronary heart disease
cancer of colon and breast.

Carbohydrates:
are composed of carbon, hydrogen and oxygen.
Cheapest source of energy(4kcal/gm).
Classification of carbohydrates:-
1. monosaccharide:-glucose.
2. Disaccharides:-sucrose, lactose.
3. Polysaccharides:-starch, glycogen.
Sources of carbohydrates:-
1. starches:-cereals, millets, roots, tubers.
2. Sugars:-monosaccharide &disaccharides.
3. Cellulose:-fibers from fruit, vegetables and cereals.
Daily requirement of carbohydrate:-400-600gm.

Function of carbohydrates:-
1. Source of energy.
2. Helps the body to use protein and fat efficiently.
3. Fiber present in carbohydrate form bulk and thus helps in digestion.

Carbohydrate deficiency results in:-
-Ketone body production.

Food hygiene:
The WHO has defined food hygiene as all conditions and measures that are
necessary during the production, storage, distribution and preparation of food to
ensure that it is safe, sound wholesome and fit for human consumption.
Food borne diseases:- A infectious or toxic disease, caused by agents that enter
the body through the ingestion of food.

Classification of food borne diseases:-
1. Food borne infections:-
a. Bacterial:- Typhoid, Cholera, Salmonellosis, Shigellosis.
b. Viral:- Viral hepatitis, Gastroenteritis.
c. Parasitic:-Ascariasis, Amebiasis.
2.Food borne intoxications:-
a. Staphylococcus poison
b. Botulism
c. Aflatoxins

Food preservation methods:-
1. Cooking-preserve food for some time.
2. Refrigeration-most of cooked & uncooked food.
3. Deep freeze-raw food items.
4. Drying-meat, fish.
5. Smoking- meat.
6. Salting-meat, fish.
7. Pickling- achar, jam, jelly.
8. Concentrated sugar solution-fruits, sweets.
9. Chemicals-vinegar.

Milk hygiene:
Milk is an ideal vehicle for disease transmission.
Milk can be contaminated by:-
1. Dairy animals
2. Human handler
3. Contaminated vessels
4. Dust, flies
5. Milk adulteration
Milk borne diseases:-
1. Tuberculosis(bovine)
2. Staphylococcal enterotoxins
3. Typhoid
4. Cholera
5. Shigellosis
Preservation methods of milk:-
1. Boiling
2. Sterilization
3. Pasteurization
4. Drying
5. Condensing
Boiling:-
The commonest method use in house. By boiling all the pathogenic
organism killed except spore. To make milk free of germ boiling for 30
minute is necessary.
Sterilization:-
Milk is heated at temperature of 100 degree centigrade for 15 minute in a
close container. It kills all germs including spore.
Pasteurization :-
According to WHO, pasteurization is defined as, heating of milk to such
temperature and for such periods of time as are required to destroy any
pathogens that may be present while causing minimal changes in the
composition, flavor and nutritive changes.
Methods:-
1. Holder method:- In this process, milk is kept at 63-66 degree C. for at least
30 minute, and then quickly cooled to 5 degree C.
2. Elash method:- milk is rapidly heated to a temperature of 72 degree C for
15 seconds and then rapidly cooled to 4 degree C. It is most widely used
method.
Food adulteration:
Extraction of valuable component from food and addition of something of lower
price which is absent in food normally, with an evil motive which lowers the food
value and has injurious effect to health is called food adulteration.
Form of adulteration:-
mixing, substitution, abstraction, putting decomposed food for sale,
addition of poison.
Commonly adultering foods are:-
Milk:- Adding water, removing cream, adding powder milk.
Flours:-Mixed with chalk powder.
Butter:- Add starch, animal fat.
Ghee:- Add vanaspati.

Food additives:-
Non-nutritious substances are added to food to improve its appearance,
flavour, texture and storage properties.
Classification:-
1. Coloring agents:- Saffron
2. Flavoring agents:- Essences like vanilla, strawberry, banana.
3. Sweaters:- Saccharin
4. Preservatives:- Sorbic acid
5. Acidity imparting agents:- Citric acid, acetic acid.

Food fortification:-
The process whereby nutrients are added to food to maintain or improve the
quality of the diet of a group, a community, or a population.
Indication of food fortification:-
1. When the nutritive value is lost in the food processing. e.g.:- vit. D adding in
wheat.
2. To improve the quality of food.eg. Adding vit. A & D in milk.
3. To prevent the specific diseases. e.g.:- Adding of iodine to prevent endemic
goiter.

Vitamin & Minerals:
Vitamins are vital accessory food factors present in minute quantities in various
food, required by the body in very small quantity for normal growth and
development of the body.
Classification of vitamins:-
Fat soluble:-A,D,E and K.
Water soluble:- vitamin B complex & vitamin C.
B complexes are:-thiamine, riboflavin, nicotinic acid, biotin, pyridoxine,
pantothenic acid, folic acid, lipoic acid, vitamin B12.

Vitamin A:
Vitamin A is also known as growth promoting and anti-infective vitamin.
Sources:-
-Animal source:-liver, egg yolk, cheese, whole milk, fish, meat.
-Plant source:-dark green leafy vegetables, colored vegetables like carrot and
pumpkin, yellow fruits.
Daily requirements:- Infant:-300-400microgm
Children:-250-600microgm
Male/Female/Pregnancy:-750microgm
Function of vitamin A:-
-Play a major role in normal vision.
-Growth and development, especially bone.
-Has anti-infective action and immunological defense mechanism.
Effect of vitamin A deficiency:-
-Night blindness
-Xerophthalmia- Means dryness of eye. Eye changes are conjunctival xerosis,
bitots spots, corneal xerosis, corneal ulceration, keratomalacia.
Treatment:-
All the early stages of xerophthalmia can be treated by administration of 200,000
IU retinol palmitate orally on two successive days.
Prevention:-
-Diet rich in vitamin A.
-Prophylactic use of high potency of oral vitamin A capsule to high risk children.

Vitamin D:
Forms of vitamin D:-
Vitamin D2 or calciferol
Vitamin D3 or cholecalciferol
Sources:-
-Natural source:-7-dehydrocholesterol present in skin convert in D3 in exposure
to sun.
-Animal source:-fish liver oil, egg yolk, liver, butter, milk.
Daily requirement:- Adults:-100 IU
Infant & children:-200 IU
Pregnancy & lactation:-400 IU.

Function of vitamin D:-
-Formation of healthy bone and teeth.
-It stimulate intestinal cells to synthesize calcium binding protein, which helps in
calcium absorption.
-Increase renal reabsorption of phosphorus.
Effect of vitamin D deficiency:-
-Rickets disease of children 6 months to 2 years characterized by growth failure,
bone deformity, muscle hypotonia, tetany and hypocalcaemia.
-Ostomalacia-adults.
Prevention:-
-Exposure children regularly to sunshine.
-Periodic dosing with vitamin D.
-Vitamin D fortified food.

Vitamin E/ Tocopherol:
Sources:-
-Plant source:-vegetable oils, wheat germ oil, fruits and vegetables.
-Animal source:-egg yolk, fish, meat, milk.
Daily requirement:- 10mg/day.
Function:-
Acts as antioxidant.

Vitamin K:
Forms of vitamin K:- K1 & K2.
Sources:-
-Source of vitamin K1:-dark green leafy vegetables, fruits.
-Source of vitamin K2:-endogenous synthesis by intestinal bacteria.
Daily requirement:- 0.03mg/kg.
Function of vitamin K:-
-Stimulates the production and release of certain clotting factor.(stable factor-vii).
-Helps in blood clotting.
Effect of vitamin K deficiency:-
-Prolonged clotting time.
-Generalized bleeding manifestation due to hypoprothombinemia.

Thiamine/Vitamin B1:
Sources:-
Plant source:-whole grain, wheat germ, pulses, nuts, vegetables, fruits.
Animal:-meat, fish, eggs.
Functions:-
Utilization of carbohydrate in body.
Essential for proper functioning of the nervous system.
Daily requirement:- Male:-1.5mg
Female:-1mg
Effect of thiamine deficiency:-
1. Beriberi:-exist in 3 forms.
-Wet beriberi/ cardiac beriberi:-heart enlargement with CCF.
-Dry beriberi/ neuritic beriberi
-Infantile beriberi
2. Wernicks encephalopathy:- Characterized by ophthalmoplegia, polyneuritis,
ataxia and mental deterioration.

Riboflavin/vitamin B2
Sources:-
Animal source:-liver, kidney, fish, meat, eggs.
Plant source:-green leafy vegetables and pulses.
Daily requirement:- Male:-1.6mg
Female:-1.4mg
Functions:-
-Helps in cellular oxidation.
-Acts as co-factors in metabolism.
Effect of deficiency:- Angular stomatitis, Glossitis, Cheilosis.

Niacin:
Sources:-
Animal :-liver, kidney, fish, meat, milk.
Plant :-legumes, groundnut.
Daily requirement:- male:-18mg, female:-14mg
Functions:-
-Essential for metabolism of carbohydrate, protein and fat.
-Essential for normal functioning of skin, intestinal tract, nervous system.
Effect of deficiency:-
Pellagra:-characterized by 3 Ds. diarrhea, dermatitis, dementia.
Glossitis
Stomatitis

Pyridoxine/vitamin B6:
Sources:-
Animal :-meat, fish, milk, egg.
Plant :-vegetables, whole grain.
Daily requirement:- 2mg.
Function:-Helps in metabolism.
Effect of deficiency:-Peripheral neuritis.

Folate:
Sources:-
Animal :-liver, meat, milk, egg.
Plant :-leafy vegetables, fruits.
Daily requirement:-
Adult/children:-100 microgm.
Pregnancy:-300 microgm.
Lactation:-150 microgm.
Function of folate:-
Synthesis of nucleic acid.
Needed for development of blood cell in bone marrow.
Megaloblastic anemia.
Glossitis.
GIT disturbances:-diarrhea, distension.
Infertility.

Cyanocobalamin/vitamin B12:
Sources:-
Animal source:-liver, kidney, meat, fish, milk, cheese.
No plant source.
Daily requirement:- Adult:-1 microgm
Pregnancy:-1.5 microgm.
Functions:-
Synthesis of DNA.
Synthesis of fatty acid in myelin.
Megaloblastic anemia.
Demyelinating neurological lesions in spinal cord.

Vitamin C/ Ascorbic acid:
Vitamin C is most sensitive of all vitamins to heat.
Daily requirement:-
Adult/pregnancy/children:-40mg
Lactation:-80mg
Sources:-
Plant source:-citrus fruit, green leafy vegetables.
Animal source:-meat, fish, milk.
Functions:-
-Enzymatic role
-Wound healing
-Hemorrhage
-Iron absorption
-Maturation of RBC.
Effect of vitamin C deficiency:-
Scurvy-characterized by swollen and bleeding gums, bleeding from skin and joints,
delayed wound healing and anemia.

Minerals: The human body contains more than 50 chemical elements which
required for growth, repair and regulation of vital body functions, called minerals.
1. Major minerals:-calcium, sodium, potassium, phosphorous, magnesium.
2. Trace minerals:-iron, iodine, fluoride, zinc, copper, cobalt, chromium,
manganese, molybdenum, nickel, tin, silicon and vanadium.
3. Trace contaminants with no known function:-mercury, barium, boron and
aluminium.

Calcium:
The body of an adult normally contains about 1200 gm of calcium.
At least 99% of this is present in skeleton.
Sources:-
Milk &milk products, eggs, fish eaten with bone, green leafy vegetables, some
nuts-almond.
Daily requirement:- Adult:-400-500 mg
Pregnancy:-1000 mg
lactation:-1200 mg
Infants:-500-600 mg
Function of calcium:-
-Formation of bone and teeth.
-Coagulation of blood.
-Controls many life processes, like muscle contraction, cardiac action, cell division,
metabolism of enzyme & hormones.
-Transformation of light energy to electrical impulses in the retina.
Effect of calcium deficiency:-
-Decreased rate of growth
-Osteoporosis
-Tetany

Iron:
There are 2 forms of iron. Heme iron & non heme iron.
Sources:-
Heme iron:-animal source(liver, meat, fish).
Non heme iron:-animal source(green leafy vegetables & dry fruits).
Daily requirements:- Infant/children:-20-25mg
Male:-24mg
Female:-32mg
Pregnancy:-40 mg

Function of iron:-
-Formation of hemoglobin.
-Brain development.
-Oxygen transport and cell respiration.
Routes of iron loss:-
-Hemorrhagic loss:-whenever blood is loss iron is loss. Causes are:-
-Physiological loss:-menstruation, delivery.
-Pathological loss:-hookworm infestation, malaria, hemorrhoids, peptic ulcers.
-Basal loss:-loss through urine, sweat, bile.
Effects of iron deficiency:-
-Anemia
-Impaired cell mediate immunity

Iodine:
Iodine has heaviest atomic weight of all essential elements.
Source of iodine:-
-Best sources are:-sea foods like sea fish, sea salt, cod liver oil.
-Milk, meat, vegetables contain iodine in small amount.
-Artificial source:-iodized table salt.
Daily requirements:- Children:-100microgm
Adults:-150 microgm
Function of iodine:-
-Synthesis of thyroid hormones- thyroxine (T4), triiodothyronine (T3).
-It is essential in normal growth and development.
Effects of iodine deficiency:-
-Hypothyroidism.
-Retarded physical development and mental function.
-Chances of spontaneous abortion and still birth.
-Cretinism.
-Endemic goiter.

NUTRITION & MALNUTRITION:
Balance Diet : A balance diet is one, which contains different types of food in such
quantities and proportion that is needed for energy, maintaining health, vitality
and general well-being and also makes a small provision for extra nutrients to
withstand short duration of leanness.
Criteria of a balance diet:
-Easily available.
-Sufficient to satisfy taste and appetite.
-It should be easily digestible, absorbable.
-Protein and fat should be obtained from both animal and plant sources.
-It should contain sufficient vegetables and fruits.
-Vitamins and mineral should be in sufficient quantities.
Diet of pregnant mother:
-Energy intake:-An additional minimum intake of 200 kcal/day.
-Proteins:- An additional allowance of 14gm/day.
-Other nutrients:- A regular and adequate intake of all other nutrients,
specially iron, folic acid and calcium.
Diet of lactating mother:
-Energy intake:-An additional minimum intake of 550 kcal/day for the first 6
months and 400 kcal/day from 6 months to 1 year.
-Proteins:- An additional allowance of 25 gm/day.
specially vitamin C.
Diet of growing children:
-Energy intake:-With advance in age there is increase in calorie
requirement. A child aged 1 year, energy requirement is 1000 kcal/day.
After 1 year addition 100kcal required for every year of life. Thus at age 5
yrs 1500kcal/day.
-Proteins:- Extra protein needed to ensure proper growth of tissue.
specially calcium, iron.
Milk an ideal food:
Milk is unique in nutritive value and contains all the food factors of a well
balanced diet required for human body.
It is an ideal food for infants up to 6 months.
The food factors present in milk are:-
1. protein:-casein, lactalbimin and lactglobulin. Milk protein contains all
essential amino acids.
2. Fats:-milk fat is good source of vitamin A and vitamin D.
3. Carbohydrate:- lactose is milk sugar, which is found no where in nature.
4. Minerals:- milk contains almost all the minerals needed by the body.
5. Vitamins:-milk is good source of all vitamins except vitamin E.
6. Water:- milk contains 87% water.
7. Enzymes:- amylolytic, proteolytic and lipolytic are present.
Humanization of cows milk:
Cows milk is suitably changed to make it comparable to mothers milk and make
suitable drink for new born baby.
Principle:-
-The insoluble caseinogens of cows milk must be reduced to the level as
present in human milk.
-The amount of lactogen must be increased to the right proportion and the
resulting mixture mast be pasteurized.
Procedure of humanization:-
1. Adding one part of water to one part of cows milk, this will bring down the
protein content to that of mothers milk. This will cause sugar and fat to
come down.
2. So, add 1 oz of milk sugar and 1 oz of ordinary centrifuged cream should be
added to 1 pint of diluted milk.
3. Vitamin C (10 cc of orange or tomato juice)should be added.
(1 pint=16 ounce=473ml, 1cc=1ml)
Nutritional Status:
Nutritional status is the end result of utilization of the nutrients by the body.
Nutritional status can be assess by:-
1. Nutritional anthropometry
2. Clinical examination
3. Bio-chemical evaluation
4. Dietary survey
5. Functional assessment
6. Vital and health statistics

Nutritional anthropometry:-
1.Height (cm) and weight(kg):-
a. Weight for age- index for malnutrition.
b. Height for age-gives a picture of past nutritional history.
c. Weight for height-index of current nutritional status.
2.Area circumference- like mid arm circumference.
3. Skin fold thickness-measure skin calipers over triceps.

Clinical examination:-
Bitots spot, angular stomatitis,
rickets, goiter, Megaloblastic anemia.

Biochemical evaluation:-
Hemoglobin - anemia

Dietary survey:-
Assessment of food consumption
Calculation of nutritive value of food.

Functional assessment:-
Specific function is seen.
Vitamin K prothrombin time

Vital and health statistics:-
IMR, still birth, perinatal mortality rate.

Malnutrition:
Malnutrition is an impairment of health resulting from a deficiency, excess or
imbalance of nutrients.
Malnutrition comprises 4 forms:-
1. Under nutrition:- due to insufficient food intake for long period.
2. Over nutrition:- due to excess food intake for certain period.
3. Imbalance:- disproportion among essential nutrients.
4. Specific deficiency:- relative or absolute deficiency of any nutrients

Major health problems:
-Protein energy malnutrition
-Vitamin A deficiency
-Iron deficiency
-Iodine deficiency

Protein energy malnutrition:
Types of PEM: Kwashiorkor
Marasmus
Cause of PEM:-
1. Inadequate diet
2. Infection and parasitic diseases
3. Failure lactation
4. Poor environmental condition

Difference between Kwashiorkor and Marasmus:

Features Marasmus Kwashiorkor

1.Cause

2.Clinical features:-
a. Edema
b. Muscle wasting
c. Growth retardation
d. Hepatomegaly
e. Skin changes
f. Mental changes

3. Appearance

4. Usually occur in

1. Deficiency of calories.

2.
a. Absent
b. Severe
c. Severe
d. Absent
e. Absent
f. absent

3. Old mans face

4. First year of life.

1. Deficiency of protein.

2.
a. Present in legs.
b. Less
c. Less
d. Present
e. Scaly, discoloration
f. Present

3. Moon face

4. Second year of life.

Picture of Marasmus:
Picture of kwashiorkor

Xerophthalmia: (Vit A Deficiency)
The meaning of Xerophthalmia is disease due to dry eye.
The term Xerophthalmia refers to all the ocular manifestation of vitamin A
deficiency, from night blindness to complete corneal destruction.
WHO classification of Xerophthalmia:
XN :- Night blindness
XIA :- Conjunctival xerosis
XIB:- Bitots spots
X2:- Corneal xerosis
X3A:- Keratomalacia/ corneal ulceration <1/3
rd
surface.
X3B:- Keratomalacia/ corneal ulceration >1/3
rd
surface.
XS:- Corneal scar.
XF:- Corneal fundus.
WHO treatment schedule of Xerophthalmia for child 1-6 years of age:
1. Immediately on diagnosis:- 200,000 I.U. vitamin A orally.
2. The day following diagnosis:- 200,000 I.U. vitamin A orally.
3. 4 weeks later :- 200,000 I.U. vitamin A orally.

WHO treatment schedule of Xerophthalmia prevention:
1. Infants 6 -12 months:- 100,000 I.U. of vitamin A orally every 3-6 months.
2. Child 1-6 years age :- 200,000 I.U. of vitamin A orally every 3-6 months.
3. Lactating mothers :-200,000I.U. of vitamin A orally once at delivery or
during next 2 months.

MATERNAL & CHILD HEALTH
Definition:- The promotive, preventive, curative and rehabilitative health care for
mother and children up to pre school ager.
Components of MCH:-
1. Antenatal /prenatal care
2. Intra natal care
3. Post natal care
4. Family planning
5. Care of the new born

Aims and objective of MCH:-
1. To provide adequate antenatal, intra natal and postnatal care.
2. To ensure proper equipments, drugs and other facilities.
3. Health education to the pregnant women and mothers.
4. MCH care should include family planning.
5. Well baby care clinic for immunization, treatment of baby.

Maternal health care:
WHO definition of maternal mortality:-
The death of a woman while pregnant or within 42 days of termination of
pregnancy, irrespective of the duration and site of pregnancy, from any cause,
related to or aggravated by the pregnancy or its management but not from
accidental or incidental causes.
Maternal cycle:-
1. Fertilization
2. Antenatal
3. Intra natal
4. Post natal
5. Inter conceptional period.

Antenatal care(ANC):
Care of the woman during pregnancy.
Aim:- To achieve healthy mother and healthy baby at the end of pregnancy.
Importance of ANC:-
1.Promote, protect & maintain health during pregnancy.
2.Detect high risk cases during ANC examination and take proper action during
delivery.
3.Many maternal diseases diagnosed and treated, which prevent transmission to
infant. e.g syphilis, hepatitis.
4.Tetanus immunization to mother can prevent tetanus neonatorum to infant.
ANC visit:-
Standard:- Total 14 visits
Every 4 week up to 32 weeks.
Every 2 week from 32-36 weeks.
Every week from 36 weeks till delivery.
Intermediate:- Total 5 visits
1
st
: before 12 week
2
nd
: 20-22week
3
rd
: 28-32 week
4
th
: 34-36week
5
th
: 38- till delivery
Minimum:- Total 3 visits
1
st
visit: 4-12 weeks
2
nd
visit: 24-26 weeks
3
rd
visit: 36-38 weeks.

Activities during Antenatal visit:
1. Registration of the pregnant women.
2. History taking
3. Antenatal examination
4. Essential investigation
5. Advice
History taking:-
a. History about current pregnancy:- LMP, menstrual cycle, bleeding P/V.
b. Past obstetric history for multipariety:- pervious pregnancy and labour,
abortion, premature labour, intra-uterine death, eclampsia, still birth.
c. General medical and surgical history:- heart disease, asthma, diabetes,
epilepsy, STDs.
d. Family history:-diabetes, hypertension, genetic disease, twin birth.
e. Social history:- education, social status.
Antenatal examination:-
a. General examination:- height, weight, anemia, B.P., edema, jaundice, any
deformities.
b. Obstetrical examination:-breast & nipples, fundal height, lie, presentation
& position of baby, FHS, vaginal examination.
Antenatal investigation:-
Hb, BG. RBS, pregnancy test, urine sugar, urine albumin, VDRL for syphilis, rubella
antibodies, tuberculin test, hepatitis B antigen, USG.

Antenatal advice:-
diet, personal hygiene, rest, sleep, exercise, drugs, avoid radiation, warning signs,
regular follow up, family planning, health education, child care.

Warning signs:- mothers are advice to report immediately incase of following
warning signs:-
Swelling of feet, convulsion, blurring of vision, headache, per vaginal bleeding.

High risk pregnancy:
Pregnancy with added risk for complication of mortality and morbidity to be
faced by the mother and her unborn baby.
Causes of high risk pregnancy:-
1.Obstetric causes:-
Gravidity:- all Primigravida, grand multipara, elderly Primigravida
Age:- more than 35 yrs and less than 18yrs.
Height :- less than 5 feet.
Multiple pregnancy
Bad obstetric history:-previous repeated premature labour and abortion, Pre
eclamptic toxaemia, IUD, CPD, still birth.
Current pregnancy complication:- threatened abortion, PET, APH, twin pregnancy,
IUGR, low lying placenta.
2. Medical causes:-
HTN, DM, PTB, pyelonephritis, anemia, syphilis, hepatitis, psychiatric disorder.

Intra natal care:
Care of the mother at the time of delivery.
Objective of intra natal care:-
1. To ensure that mother receives the best available care during delivery.
2. To prevent maternal mortality and morbidity.
Types of intra natal care:-
1. Domiciliary/ home care
2. Institutional/hospital care
1. Domiciliary/ home care:-
Mothers with normal obstetric history can be advice to have their confinement
in their own homes, provided the home condition are satisfactory. Such delivery
may be conducted by health worker, trained dai is known as domiciliary care.
Advantages :-
1. Homely environment.
2. Cross infection less.
3. Mother will be able to look after domestic works.
Dis advantages:-
1. Less medical or nursing supervision.
2. Mother will have less rest.
3. Early bound with domestic works.

2. Institutional/hospital care:-
This recommended for all high risk pregnancy and where home condition is not
suitable.
The length of hospital stay vary with the nature of cases.
Advantages :-
1. More medical and nursing supervision.
2. Mother gets more rest, better diet.
Dis advantages :-
1. Cross infection more.
2. Fear or nervousness to mother.

Postnatal care:
Care of mother and baby after delivery.
Importance of PNC:-
1.Helps in early detection & prevention of complication.
2.Helps to restore mothers health through rest and balance diet.
3.Educate and encourage mothers for breast feeding.
4.Counseling about spacing and family limitation.
Complication during postnatal period:-
Puerperal sepsis, thrombo-phlebitis, secondary PPH, UTI, mastitis.

Child health:
Live birth:- means that the child show signs of live when only part of the child is
out of mother, during delivery process.
Still birth:-is one, which is born after 28 weeks of gestation, and did not breath or
show any other sign of life, after being completely born.
Dead birth:-is one, which has died in uterus and may shows sign of rigor mortis,
maceration or mummification after birth.
Perinate:- Period from 28 wks of gestation to 7 days of life.
Perinatal death:- death of fetus after 28 wks of gestation till 7 days of life.
Neonate:- period from birth to 28 days of life.
Neonatal death:-death of baby within 28 days of life.
Infant :- period from 7days of life till 1 year.
Infant death:- death of baby from 7 days till 1 year.
A. Immediate care of new born:
-Immediately after head is born, wipe eye, mouth and nose of baby.
-After baby is fully born wrap baby by warm cloth and keep in tray in warm
place.
-Care of airways:-clean mouth & nasopharynx. If secretion is present
cleaned by mucus sucker. Look for cry of baby, which initiate respiration.
-Resuscitation:-if baby dont cry for 1 minute, there is no respiration. Then
immediately resuscitation to be started by oxygen.
-Care of cord:-cut and ligate umbilical cord 5 cm away from base of
umbilicus and have to clean daily by antiseptics.
-Care of eye:-cleaned by sterile wet swab.
-Baby bath:- by Luke warm water.
-Feeding :-exclusive breast feeding.

B. Assessment of the physical status of newborn by Apgar score:
A quantitative rating test based in activity, pulse, grimace, appearance,
respiration of a newborn a minute or so after birth. A score greater than 7
signifies good health with a maximum of 10.

Apgar scoring chart

C. Examination for abnormalities
-Cyanosis of lips & skin.
-Any difficulty in breathing.
-Imperforated anus.
-Persisting vomiting.
-Signs of cerebral irritation. E.g.:-twitching, convulsion, neck rigidity, bulging of
anterior fontanel and temperature instability.

At risk babies:
Criteria of at risk babies:-
A. Related to baby:-
1. Twin, low birth weight
2. Insufficient or absence of Breastfeeding.
3. Fail to gain weight during 3 successive months.
4. Loss of weight during 2 successive months.
5. Birth order more than 5.
6.Spacing less than 2 yrs.

B. Related to parents:-
1.Child with single parents.
2.H/O death of 2 or more siblings within 2 yrs.

Low birth weight:
According to WHO, a low birth baby is one with a birth weight of less than 2500
gm, within the first hours of life, before significant postnatal weight loss.
Causes of LBW:-
A. Maternal factors:-
-Nutrition:-malnutrition, iron & folic acid deficiency.
-Infection:- UTI, syphilis, hepatitis.
-Chronic diseases:-DM, HTN, heart & renal diseases.
-Tumor:-ovarian
-Drugs:- phenobarbitone, methyl dopa, steroids.

B. Obstetric factors:-
-Toxaemia of pregnancy
-Ante partum hemorrhage
-Premature rupture of membrane

C. Uterine factors:-
-Uterine malformation, like bicornuate, septate.

D. Fetal factors:-
-Multiple pregnancy
-Hydramnious
-Intrauterine infection
-Congenital anomalies.

GOBI-FFF:
The UNICEF has put forward a set of 7 strategies for child health revolution,
popularly known as GOBI-FFF.
G:- growth monitoring (by growth chart)
O:- oral rehydration(Rx. mild-moderate dehydration)
B:- breast feeding
I:- immunization
F:- female education
F:- frequent feeding
F:- family planning
Breast feeding:
Breast milk is ideal food for baby up to the age of 6 months.
The amount of milk required by the baby is 170ml/kg/day for the first 6 months.
Types of breast feeding:-
1. Demand feeding:- Breast milk is feed, whenever baby cries due to hunger.
2. Regular feeding:- Breast milk is feed every 3 hourly during day time and 6
hourly during night time.
3.
Advantages of breast feeding
1. To baby :- Remember BREAST FEEDING
B:- Best for baby.
R:- Require no preparation.
E:- Economic.
A:- Antimicrobial factors like, lysozyme, lactoferrin.
S:- Sterile, safe, hygienic.
T:- Temperature accurate.
F:- Free of infectious agent.
E:- Easily digestible.
E:- Easily available.
D:- Diarrhea prevention .
I:- Immunoglobine like, Ig G, Ig A, Ig D, Ig E, Ig M.
N:- Nutrient sufficient.
G:- Growth of jaw by suckling.
2. To mother :-
a. Psychological bonding between mother and baby.
b. Prevent ovulation and acts as contraceptives.
c. Prevent carcinoma of breast.
d. Removes excess fat deposition in body as fat goes to milk.
e. Suckling stimulate oxytocin release and helps evolution of genital organs.

Disadvantages of breast feeding:-
1.Maternal proximity i.e. bound with child.
2.Complication like breast abscess, crack nipple.

Contra-indication of breast feeding:-
Maternal cause :-
1. Mother with severe psychiatric disorder.
2. Disease like:- active tuberculosis, chronic nephritis, septicemia, eclampsia,
breast tumor.
3. Mother treated with anti cancer drugs.
Child cause :-
1.Galactosemia
2. Phenylketonuria
3. Gross prematurity of baby.
Difficulties in breast feeding:-
Maternal cause:-
1. Cracked nipple
2. Breast abscess
3. Poor health of mother

Baby cause:-
1. Cleft palate.
2. Cleft lip.
3. Cerebral trauma.

Colostrums:
It is the secretion of breast during first 2-3 days of delivery, which contains
greater amount of protein, calorie, antibodies and lymphocytes.
Contents of colostrum:-
1. Protein ( high)
2. Sugar (less)
3. Minerals (high)
4. Antibody esp. Ig A
5. Fat (less)
Importance of colostrum:-
1.Antibody esp. Ig A protect against infection.
2.Colostrum helps to sterile the small intestine, if it is contaminated by infected
swallowed during birth.

Weaning:
It is the process of gradual withdrawal of breast milk from breastfeeding child and
introduction of soft supplementary foods like soft rice, smashed potato, eggs
from 6 months of age.
Importance:-
1.To prevent from malnutrition like kwashiorkor, marasmus, immunodeficiency.
2.To prevent from infection like diarrhea, ARIs.
3.To prevent growth failure.

Artificial feeding:
It is a condition, when baby is completely deprived of mothers milk due to some
maternal or other factors and entirely dietary demand of baby is met from other
source of food.
Causes of artificial feeding:-
1. Failure of breast milk.
2. Contraindication of breast milk.
3. Death of mother.
Breast milk substitutes:-
Powder milk, cows milk, goats milk, vegetable milk.

Milk injury:
It is a condition developed when a baby is only breastfeed for prolong period of 1-
1
1/2
years.
Due to deficiency of iron and vitamin C. Because, though milk is ideal food it
contains less vitamin-C and iron. So baby first develop iron deficiency anemia and
scurvy.
Baby become apathetic, dull, flabby, anemic, susceptible of infection, swollen
joints and bleeding manifestation.

Indicators of MCH care
1. Maternal mortality rate (MMR)
2. Infant mortality rate (IMR)
3. Neonatal mortality rate
4. Post- neonatal mortality rate
5. Perinatal mortality rate
6. Under 5 (1-4yrs) mortality rate

Maternal mortality rate (MMR):
It is the total number of death of woman during pregnancy, delivery or post
partum period not related with medical , surgical or accidental causes per 1000
live birth per a year in a given population.
Cause of high MMR:-
1. Toxaemia of pregnancy
2. Hemorrhage:- APH, PPH
3. Obstructed labour
4. Septic abortion
5. Poor ANC
6. Severe anemia

Prevention of MMR:-
1. Dietary supplementation including correction of anemia.
2. Prevention of hemorrhage.
3. Prevention of complication.
4. Treatment of medical conditions like hepatitis.
5. Promotion of family planning.

Infant mortality rate (IMR):
The total number of death of infant per 1,000 live births in one year.
It is one of the most universally accepted indicator of health status.
Cause of high IMR:
A. Neonatal cause (0-4 weeks):-
1. Prematurity
2. IUGR
3. Birth injury and asphyxia
4. Congenital anomalies
5. Neonatal tetanus
B. Post-Neonatal cause (1-12 months):-
1. Lower respiratory tract infection.
2. Gastro-intestinal and diarrheal disease.
3. Communicable diseases.
4. Sudden infant death syndrome.

Cause of under-5 mortality & their prevention:
Causes: Prevention
1. Diarrheal disease
2. Measles
3. Acute respiratory infection
4. Malaria

5. Tetanus

1. ORS
2. Measles vaccination
3. Antibiotics
4. Anti malarial drugs and
prevention of mosquito bite
5. TT immunization

SEXUALLY TRANSMITTED INFECTIONS (STI):
Sexually transmitted infections (STIs) are infections whose primary route of
transmission is through sexual contact.
STIs can be caused by mainly bacteria, viruses, or protozoa.
In the developed world, viral diseases have become increasingly common and
important, whereas bacterial STIs are more common in developing countries, but
even this is changing with the increasing recognition of viral diseases.
The three most common presenting symptoms of an STI are urethral discharge,
genital ulceration, and vaginal discharge with or without vulval irritation.
Trichomoniasis, pediculosis pubis, genital warts, chlamydial infections,
gonococcal infections and genital herpes are common
Scabies and vaginal candidiasis often are diagnosed in STI clinics, although they
are not usually acquired sexually.

Why STIs are important?
-Common
-Often asymptomatic
-Major complications and sequelae
-Expensive
-Synergy with HIV

Protozoal STDs: Trichomoniasis
Viral STDs: HPV, HIV, Hepatitis B, Herpes simplex
Bacterial STDs: Gonorrhea, Syphilis, Chlamydia

Major sequel of STIs:
WOMEN MEN INFANTS
Cancers

-cervical cancer
-vulval cancer
-vaginal cancer
-anal cancer
-liver cancer
-T cell leukemia
-kaposis sarcoma
-penile cancer
-anal cancer
-liver cancer
-T cell leukemia
-kaposis sarcoma

Reproductive health
problem
-Pelvic
inflammatory
disease
-infertility
-ectopic pregnancy
-spontaneous
abortion
-Epididymitis
-Prostatitis
-Infertility

Pregnancy related
problems
-preterm delivery
-premature rupture
of membranes
-puerperal sepsis
-postpartum
infection
-Still bith
-low birth weight
-pneumonia
-acute hepatitis
-congenital
abnormalities

Neurological
problems

neurosyphilis Neurosyphilis -cytomegalovirus
-herpes simplex
virus
-syphilis associated
neurological
problems
Other common
health
-Chronic liver
diseases
-Chronic liver
diseases
-Chronic liver
diseases
consequences

-Cirrhosis -Cirrhosis -Cirrhosis

Role of STIs in the acquisition of HIV
-HIV acquisition increases by twofold to fivefold in the presence of other STIs
-Ulcers disrupt mucosal integrity and increase the presence or activation, or both,
of HIV susceptible cells
-Non-ulcerative STIs (such as gonorrhoea, chlamydia,Trichomonas vaginalis, and
bacterial vaginosis) increase the presence or activation, of HIV susceptible cells

Size of the problem:
-The World Health Organization (WHO) has estimated a total of 340 million new
cases of curable STIs in adults per annum, mainly in South East Asia(151 million
new cases per year)and Africa(69million).
-In eastern Europe and Central Asia, the estimate is 22 million, and 17 million in
western Europe.
-The prevalence and incidence per million of the population varies regionally, for
example between sub-Saharan Africa and western Europe it is eightfold and
fourfold, respectively.

Why are STIs increasing?
-Attitudes towards sex and sexual behaviour have changed(Like many other
medicosocial conditions, suicide,alcoholism, cancer, and heart disease)
-Age at first intercourse has declined, and half of all teenagers have sex before
they are 17 years of age
-The number of lifetime male and female heterosexual partners has increased
-The proportion of men and women who have concurrent relationships (having
more than one sexual partner at the same time) has increased
-Unsafe sex in homosexual men has increased
-Populations are now more mobile nationally and internationally.
-Certain groups (tourists, professional travellers, members of the armed forces,
and immigrants) are at risk.
-In addition, poverty, urbanisation, war,and social migration often result in
increased levels of prostitution.

Principles of control:
-Prevention can be aimed at uninfected people in the community to prevent them
from acquiring infection (primary prevention) or at infected people to prevent the
onward transmission of the infection to their sexual partners (secondary
prevention).
-The three basic elements of primary prevention are: health education,provision
of condoms, and social, cultural and economic interventions

Principles of effective STI control:
-Reduce infectiousness of STIs
-Condoms
-Reduce duration of infection
-Encourage diagnosis and treatment of symptomatic infection(encourage health
seeking behaviour) and asymptomatic infection (screening, partner notification,
and mass or targeted treatment)
-Reduce risky behaviour
-Reduce rate of partner change
-Delay onset of sexual intercourse
-Improve selection of partners

Primary prevention:
-Behavioural interventions are aimed at enhancing knowledge,skills, and attitudes
to help people protect themselves against infection (for example, health
promotion to decrease partner change and increase condom use)
-Structural interventions are aimed at broader societal and economic issues that
drive the spread of STIs
-Biomedical interventions include condoms, vaccines, vaginal microbicides, or
male circumcision to prevent the acquisition of infection.

Ways for an individual to reduce their risk of contracting an STI:
-Abstain
-Have a mutually monogamous relationship with someone who is uninfected.
-Select partners whose past and current behaviour puts them at low risk of
infection.
-Consider both being screened for infection before unprotected sex
-Reduce the numbers of sexual partners
-Avoid sex with people who have symptoms of a STI or oral cold sores
-Use condoms consistently on every occasion with all partners
-In open relationships couples agree to have only non-penetrative or protected
sex outside their main relationship

Structural interventions:
-Community level (for example, legislating to change the age of consent for
homosexual men or inheritance laws)
- Organisational level (for example, providing reproductive health clinics in
schools or the workplace)
- Individual level (for example, microfinance initiatives that seek to train women
to become less economically dependent

Secondary prevention:
-Enhancing health seeking behaviour
-Improving access to for STIs diagnosis and treatment
- Ensuring appropriate case management
- Early detection and treatment of symptomatic and asymptomatic infection
-Partner notification (contact tracing)

Specialist services for STIs:
- Genitourinary medicine
- Features of service
- Open access and free
- Confidential
- Screening and treatment for STIs
- Screening and treatment for HIV
- Contraception and psychosexual problems
- Miscellaneous care (for example, for urinary tract infections and genital
dermatological conditions)
- Partner notification
- Health promotion, counselling, and advice
- Outreach and special services
- Training and research

Sexual history taking:
- Symptoms (including duration)
- Last sexual intercourse
- Sex of partner
- Relationship with partner (casual, long term,traceable, etc)
- Use of barrier contraception
- Sites of exposure (oral, vaginal, or anal)
- Last previous partner or partner change (with site of exposure and barrier
contraception history as above)
- Partners symptoms
- Previous STIs or testing for STIs including HIV

Control of Sexually Transmitted Infections:
The main principles of the control of STIs are to:
- prevent new infections;
- treat those with symptoms of infection and interrupt onward transmission
such treatment should prevent the development of disease complications and
sequelae;
- identify and treat those without symptoms by screening and partner
notification;
- motivate health seeking behavior among those who may know they are infected
but who delay or avoid seeking treatment.
-high rates of infection among young adults, adolescents and certain groups (e.g.
commercial sex workers, truck drivers);
-asymptomatic infection;
-long-term morbidity, particularly in women;
- increased acquisition of HIV in transmission;
- disadvantaged and disempowered women;
-the complex mix of social, political, cultural, demographic and economic factors

Prevention & Control:

(I) Prevention:
The goals of medicine are to promote health, to preserve health, to restore health
when it is impaired, and to minimize suffering and distress.
These goals are embodied in the word "prevention"

Definition: Actions aimed at eradicating, eliminating or minimizing the impact of
disease and disability, or if none of these are feasible, retarding the progress of
the disease and disability.
The concept of prevention is best defined in the context of levels, traditionally
called primary, secondary and tertiary prevention. A fourth level, called
primordial prevention, was later added.

Determinants of Prevention:
Successful prevention depends upon:
-a knowledge of causation,
-dynamics of transmission,
-identification of risk factors and risk groups,
-availability of prophylactic or early detection and treatment measures,
-an organization for applying these measures to appropriate persons or groups,
and
-continuous evaluation of and development of procedures applied

Preventable Causes of Disease:
Remember BEINGS
-Biological factors and Behavioral Factors
-Environmental factors
-Immunologic factors
-Nutritional factors
-Genetic factors
-Services, Social factors, and Spiritual factors

Levels of Prevention:
1. Primordial Prevention
2. Primary Prevention
3. Secondary Prevention
4. Tertiary Prevention

Primordial Prevention:
Primordial prevention consists of actions and measures that inhibit the
emergence of risk factors in the form of environmental, economic, social, and
behavioral conditions and cultural patterns of living etc.
It is the prevention of the emergence or development of risk factors in countries
or population groups in which they have not yet appeared
For example, many adult health problems (e.g., obesity, hypertension) have their
early origins in childhood, because this is the time when lifestyles are formed (for
example, smoking, eating patterns, physical exercise).
In primordial prevention, efforts are directed towards discouraging children from
adopting harmful lifestyles
The main intervention in primordial prevention is through individual and mass
education.

Primary Prevention:
Primary prevention can be defined as the action taken prior to the onset of
disease, which removes the possibility that the disease will ever occur.
It signifies intervention in the pre-pathogenesis phase of a disease or health
problem.
Primary prevention may be accomplished by measures of Health promotion and
specific protection
It includes the concept of "positive health", a concept that encourages
achievement and maintenance of "an acceptable level of health that will enable
every individual to lead a socially and economically productive life".
Primary prevention may be accomplished by measures designed to promote
general health and well-being, and quality of life of people or by specific
protective measures.

Health promotion:
Health promotion is the process of enabling people to increase control over the
determinants of health and thereby improve their health.

Approaches for Primary Prevention:
The WHO has recommended the following approaches for the primary prevention
of chronic diseases where the risk factors are established:
a. Population (mass) strategy
b. High -risk strategy

Population (mass) strategy:
Population strategy" is directed at the whole population irrespective of
individual risk levels.
For example, studies have shown that even a small reduction in the average blood
pressure or serum cholesterol of a population would produce a large reduction in
the incidence of cardiovascular disease
The population approach is directed towards socio-economic, behavioral and
lifestyle changes.

High -risk strategy:
The high -risk strategy aims to bring preventive care to individuals at special risk.
This requires detection of individuals at high risk by the optimum use of clinical
methods.

Secondary Prevention:
It is defined as action which halts the progress of a disease at its incipient stage
and prevents complications.
The specific interventions are: early diagnosis (e.g. screening tests, and case
finding programs.) and adequate treatment.
Secondary prevention attempts to arrest the disease process, restore health by
seeking out unrecognized disease and treating it before irreversible pathological
changes take place, and reverse communicability of infectious diseases.
It thus protects others from in the community from acquiring the infection and
thus provides at once secondary prevention for the infected ones and primary
prevention for their potential contacts.

Tertiary prevention:
It is used when the disease process has advanced beyond its early stages.
It is defined as all the measures available to reduce or limit impairments and
disabilities, and to promote the patients adjustment to irremediable conditions.
Intervention that should be accomplished in the stage of tertiary prevention are
disability limitation, and rehabilitation.

Disability limitation:
Diseaseimpairmentdisabilityhandicap

Impairment: is any loss or abnormality of psychological, physiological or
anatomical structure or function.
Disability: is any restriction or lack of ability to perform an activity in the
manner or within the range considered normal for the human being.
Handicap: is termed as a disadvantage for a given individual, resulting from an
impairment or disability, that limits or prevents the fulfillment of a role in the
community that is normal (depending on age, sex, and social and cultural factors)
for that individual.
Rehabilitation: is the combined and coordinated use of medical, social,
educational, and vocational measures for training and retraining the individual to
the highest possible level of functional ability.

(II) CONTROL:

Concept of control:
-The term disease control describes ongoing operations aimed at reducing:
-The incidence of disease
-The duration of disease and consequently the risk of transmission
-The effects of infection, including both the physical and psychosocial
complications
-The financial burden to the community.
-Control activities focus on primary prevention or secondary prevention, but most
programs combine both.

Disease Elimination:
Between control and eradication, an intermediate goal has been described, called
"regional elimination"
The term "elimination" is used to describe interruption of transmission of disease,
as for example, elimination of measles, polio and diphtheria from large
geographic regions or areas
Regional elimination is now seen as an important precursor of eradication

Disease Eradication:
Eradication literally means to "tear out by roots".
It is the process of Termination of all transmission of infection by extermination
of the infectious agent through surveillance and containment.
Eradication is an absolute process, an "all or none" phenomenon, restricted to
termination of an infection from the whole world. It implies that disease will no
longer occur in a population.
To-date, only one disease has been eradicated, that is smallpox.

Monitoring:
Monitoring is "the performance and analysis of routine measurements aimed at
detecting changes in the environment or health status of population" (Thus we
have monitoring of air pollution, water quality, growth and nutritional status, etc).
It also refers to on -going measurement of performance of a health service or a
health professional, or of the extent to which patients comply with or adhere to
advice from health professionals.

Surveillance:
Surveillance means to watch over with great attention, authority and often with
suspicion
According to another, surveillance is defined as "the continuous scrutiny
(inspection) of the factors that determine the occurrence and distribution of
disease and other conditions of ill-health"
Objectives of Surveillance:
The main objectives of surveillance are:

(a) to provide information about new and changing trends in the health status of
a population, e.g., morbidity, mortality, nutritional status or other indicators and
environmental hazards, health practices and other factors that may affect health
(b) to provide feed-back which may be expected to modify the policy and the
system itself and lead to redefinition of objectives, and
(c) provide timely warning of public health disasters so that interventions can be
mobilized.

Evaluation of control:
Evaluation is the process by which results are compared with the intended
objectives, or more simply the assessment of how well a program is performing.
Evaluation should always be considered during the planning and implementation
stages of a program or activity.
Evaluation may be crucial in identifying the health benefits derived (impact on
morbidity, mortality, sequelae, patient satisfaction).
Evaluation can be useful in identifying performance difficulties.
Evaluation studies may also be carried out to generate information for other
purposes, e.g., to attract attention to a problem, extension of control activities,
training and patient management, etc.

COMMUNICABLE DISEASES:
An illness due to a specific infectious agent or its toxic products capable of being
directly or indirectly transmitted from man to man, animal to animal or from the
environment to man or animal is termed as communicable disease.

Classification:
1. Arthropod-Borne I nfections:
a) Malaria
b) Filariasis
c) Dengue

2. Respiratory I nfections:
a) Small pox
b) Chicken pox
c) Measles
d) Rubella
e) Mumps
f) Influenza
g) Diphtheria
h) Whooping cough
i) Meningococcal meningitis
j) Tuberculosis

3. I ntestinal I nfections:
a) Poliomyelitis
b) Viral hepatitis
c) Cholera
d) Typhoid fever
e) Food poisoning
f) Amoebiasis
g) Ascariasis
h) Hook worm infection

4. Zoonsois: Those diseases and infections which are naturally transmitted
between vertebrate animals and man.
Zoonotic diseases may be due to viruses, bacteria, rickettsiae, fungi,
helminths, protozoa, arthropods or insects.

Viral: Rabies, Yellow Fever
Bacterial: Tuberculosis, Plaque, Brucellosis, Human Salmonellosis
Rickettsial: Scrub typhus, Tick typhus, Q fever
Protozoal: Amebiasis, Toxoplasmosis, Leishmaniasis
Arthropod: Scabies
Helminthic: Hydatid Disease
Fungal: Dermatophytosis, Ring worm

5. Surface I nfections:
a. Trachoma
b. Leprosy
c. Sexually transmitted diseases
d. AIDS
e. Tetanus

Common Water/Food Borne diseases:

Malaria:
Malaria is a protozoan disease transmitted by the bite of infected Anopheles
mosquitoes.
The disease is endemic in most of the tropics, including much of South and
Central America, Africa, the Middle East, the Indian subcontinent, Southeast Asia.
The four species of malaria parasites that affect humans differ in their geographic
distributions
P. falciparum is most common in sub-Saharan Africa and Melanesia
P. vivax is found mainly in Central and South America, North Africa, the
Middle East and within the Indian subcontinent;
P. ovale is found predominantly in West Africa but also in Asia; and
P. malariae occurs worldwide, although most cases occur in Africa.

Mode of Transmission:
-By bite of infected female Anopheles mosquito.
-Malaria may uncommonly be transmitted from mother-to-infant (congenital
malaria),
-by blood transfusion,
-and in non endemic areas by mosquitoes infected after biting infected
immigrants or travelers

Clinical Findings:
-An acute attack begins with a prodrome of headache and fatigue, followed by
fever.
-A classic malarial paroxysm includes chills, high fever, and then sweats.
-Headache, malaise, myalgias, arthralgias, cough, chest pain, abdominal pain,
anorexia, nausea, vomiting, and diarrhea are common.
-Seizures may represent simple febrile convulsions or evidence of severe
neurologic disease.
Physical findings:- signs of anemia, jaundice, splenomegaly, and mild
hepatomegaly.

Regimens for the Treatment of Malaria:
Uncomplicated Malaria:
Chloroquine
OR
Amodiaquine

Multidrug-resistant P. falciparum malaria:-
Artesunate plus Mefloquine

Second-line treatment/treatment of imported malaria:-
Artesunate plus 1 of the following : 1. Tetracycline
2. Doxycycline
3. Clindamycin
Severe Falciparum Malaria:
Quinine dihydrochloride

Control & Prevention:
Prevention requires A, B, C and D.
Awareness of risk.
Bite avoidance.
Chemoprophylaxis (taking preventive medicines if you are travelling to or living in
a malaria region).
Diagnosis made promptly with early treatment of an infected case.
An E can be considered for remote adventure trips. The E stands for 'Emergency
treatment with safe drugs', such as Artemesin combined with Lumefantrine.

-Use of insecticides to kill the mosquito vector.
-Use of mosquito repellents Creams,
-Use of mosquito nets

Dengue fever:
Dengue fever is a disease caused by a flavivirus that are transmitted by
mosquitoes.
Dengue has been called the most important mosquito transmitted viral disease in
terms of morbidity and mortality. Dengue fever is a benign acute febrile
syndrome occurring in tropical regions. In a small proportion of cases, the virus
causes increased vascular permeability that leads to a bleeding diathesis or
disseminated intravascular coagulation (DIC) known as dengue hemorrhagic fever
(DHF).

Types:
- Classical
- Dengue hemorrhagic fever
- Dengue shock syndrome

The dengue virus infections from the bite of an infected Aedes mosquito.
Mosquitoes become infected when they bite infected humans, and later transmit
infection to other people they bite. Two main species of mosquito, Aedes aegypti
and Aedes albopictus, have been responsible for all cases of dengue transmitted
in this country. Dengue is not contagious from person to person.

Clinical feature:
Classical: High fever:- up to 105F , Severe headache,Retro-orbital (behind the
eye) pain, Severe joint and muscle pain, Nausea and vomiting,Rash
Dengue hemorrhagic fever:- Symptoms of dengue hemorrhagic fever include all of
the symptoms of classic dengue plus, Marked damage to blood and lymph vessels,
Bleeding from the nose, gums, or under the skin, causing purplish bruises
Dengue shock syndrome:- Symptoms of dengue shock syndrome--the most
severe form of dengue disease--include all of the symptoms of classic dengue and
dengue hemorrhagic fever plus, Fluids leaking outside of blood vessels, Massive
bleeding, Shock (very low blood pressure)

Clinical criteria to hospitalize with Dengue fever:
-Severe abdominal pain
-Passage of black stool
-Bleeding into the skin or from the nose or gums
-Sweating
-Cold skin

Treatment:
-The management of dengue fever is symptomatic and supportive, including
careful management of fever, bed rest, fluid balance, electrolytes and clotting
parameters, is crucial for the case management of dengue hemorrhagic fever.
-It is important to maintain hydration. Avoid aspirin.
-Dengue hemorrhagic fever is a potentially lethal complication, affecting mainly
children. Early clinical diagnosis and careful clinical management by experienced
physicians and nurses increase survival of patients.

Prevention:
Personal protective measures are aimed at preventing mosquito bites during the
day, particularly early morning and late afternoon.
-use personal insect repellents
-use insecticide mats to kill mosquitoes
-screen living and sleeping areas
-wear long, loose clothing when outdoors
-spray indoors in dark places (eg.behind cupboards, under beds)with knockdown
spray
-The best form to control is to get rid of dengue mosquito breeding sites around
the home.
-Dengue mosquitoes breed in containers that hold water.
-These include buckets, tyres, pot plant bases, vases, boats and coconut shells.
-Roof guttering, rainwater tanks are also potential breeding sites.

Recommendations to control breeding include:
-tipping out containers which can hold water
-storing containers in a dry place
-throwing out rubbish that collects water

Filariasis:
There are eight different types of thread-like nematodes that cause filariasis.
Most cases of filaria are caused by the parasite known as Wuchereria bancrofti.

Depending on the area which the worms affect, filariasis is classified as:
Lymphatic filariasis (Elephantiasis) which affects the lymphatic system,
including the lymph nodes.
Subcutaneous filariasis- which affects the subcutaneous layer of the skin.
Serous cavity filariasis- which affects the serous cavity of the abdomen.

Filariasis is a parasitic disease transmitted by blood -feeding arthropods, mainly
black flies and mosquitoes.

Treatment:
Diethylcarbamazine (DEC) are available to treat filariasis.

Prevention:
Protect from the bites of filarial-spreading mosquitoes by using mosquito
repellent creams, mats, coils, aerosols and prevent breeding of mosquitoes with
better practice of hygiene and sanitation.

Chicken Pox:
Is highly infectious, acute contagious disease predominantly of children, though it
may occur at any age. It is characterized by fever and a rash, it is caused by
vericella zoaster virus. Chicken pox is the skin lesions to boiled chick- peas.
Epidemiology:
Occurance: Occurs world while in both epidemic and endemic forms.
Ecological Triad:
Agent: vericella zoaster (DNA virus member of herpes virus).
Host: children under 10 years of age, both sexes are susceptible.
Natural History:
Reservoir: Is a case of chicken pox.
Infective materials: Oropharyngeal secretions, lesions of the skin and mucosa.
Mode of transmission:
Respiratory droplets, direct contact.

Clinical Features:
Prodormal symptoms: Fever, Malaise, Anorexia.
Fist sign: Appearance of a characteristic rash in crops on the trunk on second
day of illness.
The rashes spread to head and extremities. Macule- papules- vesicles-
pustules- crusts. Itching is marked.

Prevention and Control:
Prevention:
Notification.
Isolation in early first week.
Disinfection of discharges from nose, throat, skin, lesions.
Immunization.

Treatment:
Antiviral therapy for immunocompromised.
Local antiseptic: Dettol, betadine, savion etc if secondary infections.
Symptomatic therapy: Analgesic, antipyretics, anti uritics.

Influenza:
commonly called "the flu," is an illness caused by RNA viruses that infect the
respiratory tract of many animals, birds, and humans. In most people, the
infection results in the person getting fever, cough, headache, and malaise (tired,
no energy); some people also may develop a sore throat, nausea, vomiting, and
diarrhea.
Type:
Influenzavirus A
Influenzavirus B
Influenzavirus C

Route of transmission:
The virus is transmitted easily from person to person via droplets and small
particles produced when infected people cough or sneeze. Influenza tends to
spread rapidly in seasonal epidemics.

Treatment:
Treatment is usually symptomatics
Amatadine and rimantidine are active only against influenza A.

Prevention:
Vaccination: H1N1 vaccine
Controlling the spread of infection:
The influenza vaccine isn't 100 percent effective, so it's also important to take
measures to reduce the spread of infection:
Wash your hands.
Contain your coughs and sneezes. Cover your mouth and nose when you
sneeze or cough.
Avoid crowds.

Measles:
is an acute highly infectious disease of childhood caused by paramyxovirus and is
clinically characterized by fever, symptoms of upper respiratory tract (coryza,
cough) followed by typical rash.
Ecological Trait:
Agent: measles ( paramyxo virus RNA virus),
Age: Children( 6 months 3 years).
Measles tend to be very serious in malnutritionised children, mortality is 400
times higher. Both sexes are affected.
Immunity: One attack of measles gives immunity for life infant acquired
immunity transplacentaly from mothers who have had measles or measles
immunization. This immunity is usually completed for first 4-6 months of life.
Environment: Incidence is higher in spring and winter.
Incidence is higher in densely populated urban areas.
Natural history: Reservoir is a case of measles.
Source of infection: Nasopharyngeal secretions, lacrimal secretions, urine.

Directly from person to person by droplet infection, droplet nuclei (non-living
substances). Fomites, air borne.

Prevention and Control:
Control measures:
1) isolation
2) bed rest
3) supportive treatment (vit A, vit.A/B)
4) immunization of contacts within 2 days of exposure.

Preventive measures:
1) active immunization (9months,0.5cc,intramuscular/sc,deltoid).
2) passive immunization (human gamma globulin
0-25ml/kg intramuscular within 5 days of exposure.
Vaccines:- Doses and schedule (0.5ml - s/c - 9months.)

Mumps:
Mumps (epidemic parotitis) is an acute contagious disease caused by a
paramyxovirus that has a predilection for glandular and nervous tissue. It occurs
most commonly in children, is usually self-limited, and is clinically characterized
by nonsuppurative parotitis.

Epidemiology:
Mumps, historically known as epidemic parotitis, was one of the most
common early childhood infections,
Reported cases of mumps have dropped 98% when compared with the
prevaccine era.
It spreads primarily in late winter and early spring
Common in both sexes,5-15 years but all are susceptible
Infectivity is lost heating at 55 to 60C for 20 minutes and after exposure to
formalin or to ultraviolet light.
Infectivity is maintained for years at temperatures of -20 to -70C.

Natural history:
Reservior is the source of infection
Infective material : salivary secretion

Direct contact,droplet infections
Entry via nose and mouth,Exit via salivary secretion

Treatment:
Conservative measures to provide symptomatic relief and adequate hydration
and nutrition.
There is currently no established role for antiviral drugs, corticosteroids, or
passive immunotherapy in the treatment of mumps

Control of Mumps:
Vaccine: Live-virus mumps vaccine is administered 0.5 cc ; commonly given in
combination with MMR (measles, mumps, rubella) vaccine
First dose is recommended at from 12 to 15 months of age
Second dose is recommended at school entry (age 4 to 6 years)
If no preschool dose is given, the second dose should be administered before
age 12

MMR Vaccine Contraindications:
Pregnancy
Febrile illness
Planned pregnancy within 3 months
Severe immunocompromised state
Blood product or immune globulin within 3 to 6 months (dose dependent)
Anaphylaxis to neomycin

MMR Vaccine Should Be Used with Caution in These Situations:
Seizure disorder
Thrombocytopenia
Egg allergy

Isolation Precautions:
Respiratory isolation should be maintained for 9 days after onset of parotitis
Infected children should be excluded from school and daycare during this
period

Pertusis:
Whooping cough (pertusis) - is a bacterial infection of the respiratory system,
caused by B. Pertusis and is clinically characterised by an insidious onset with mild
fever and an irritating cough.
Whooping cough got its name because kids who had pertusis cough a lot, and in
between coughs, they'd make a "whoop" sound when they tried to get a breath.
The child is short of breath, inhales deeply and quickly between coughs. These
breaths frequently make a whooping sound. (loud crowing inspiration)
Note:-In china this disease referred as 100 day cough, so parents can understand .

Epidemiology
Causative agent: Bordetella pertussis a gram negative bacilli which attacks
the lining of the breathing passages, producing severe inflammation and
narrowing of the airways.
Source of infection: A case of pertusis.
Infective material: Nasopharyngeal and bronchial secretions.
Host Age: It occurs at all ages but 90% of cases are children under 5 years of
age.
Sex-Female children are affected more than a male children
Environmental factors: Common in winter season, due to overcrowding, socio-
economic condition

Mainly by droplet infection, (through nasopharyngeal and bronchial
secretions) and by direct contact with infected person.

Risk groups: Children who are too young to be fully vaccinated and those who
have not completed the primary vaccination series are at highest risk for
severe illness.
Pertussis is highly contagious with up to 90% of susceptible household
contacts developing clinical disease following exposure to an index case.
Adolescents and adults become susceptible when immunity wanes.

Treatment:
is based on antibiotic therapy, which may also be prescribed to other members
of an infected person's household to prevent the spread of infection.
Symptomatic:
Admission criteria:-If < 6 months of age. If older child who has apnoeic or
cyanotic spells.
Antibiotic treatment in whooping cough:
antibiotics are effective, but do not alter the clinical course of the illness
3 days of azithromycin.
Seven days of clarithromycin.
Seven or 14 days of erythromycin.
Complication like Bronchopneumonia should be treated according to C/S.
O2 Inhalation for cyanosis.
Some time mild sedation may be necessary for spasms.
Fluid and nutritional should be appropriate.
Steroids some time said to reduce disease course.

Control:
Early diagnosis, isolation and treatment of cases and disinfection of the
discharge from nose and throat.
Avoid contacts
Active immunization. DPT immunizations are routinely given in 3 doses, each
0.5 ml at 6, 10 and 14 weeks intramuscularly.
Following immunization, a gradual drop in immunity takes place in about 75%
1 year after vaccination, so booster doses should be given to gain immunity.

Tuberculosis:
is a chronic infectious and communicable granulomatous disease caused by the
Mycobacterium tuberculosis. Tuberculosis most commonly affects the lungs(PTB)
but can also affect the central nervous system, the lymphatic system, the
circulatory system, the genitourinary system, bones, joints and even the skin.

Natural History:
Causative agent-Mycobacterium tuberculosis (MTB), is a slow-growing aerobic
bacterium that divides every 16 to 20 hours; this is extremely slow compared
to other bacteria, which have division times measured in minutes.
Source of infection-human and bovine. The most common source of infection
is human, whose sputum is positive for tubercle bacilli and who has either
receive no treatment or not been treated fully. The bovine source of infection
is usually infected milk.
Faeces, urine, pus, pleural and peritoneal fluids, gastric contents in extra
pulmonary tuberculosis
Communicability: Patients are infective as long as they remain untreated,
effective anti-microbial treatment reduces infectivity by 90% within 48 hours.
Host factors: a) Age: Tuberculosis affects all ages.
b) Sex: More common in males.
Incubation period: weeks, months or even years

TB is spread by droplets expelled by people with the active disease of the lungs
when they cough, sneeze, speak, kiss, spit
The chain of transmission can therefore be broken by isolating patients with
active disease and starting effective anti-tuberculous therapy.
(transplancental,ingestion,inoculation,)

Risk factors :
Smoking more than 20 cigarettes a day also increases the risk of TB by two- to
four-times.
Immunocompromise patient for example, AIDS, those undergoing
chemotherapy,
The risk of contracting TB increases with the frequency of contact with people
who have the disease, with crowded or unsanitary living conditions and with
poor nutrition.
Others at risk include those from areas where TB is common, health care
workers who serve high-risk clients, medically under served, low-income
population, children exposed to adults in high-risk categories

Symptoms:
A productive, prolonged cough of more than three weeks duration,
chest pain and coughing up blood.
Systemic symptoms include fever, chills, night sweats, appetite loss, weight
loss and anemia, easily fatigued.
When the infection spreads out of the lungs, extra pulmonary sites include the
pleura, central nervous system in meningitis. Extra pulmonary forms are more
common in immunosuppressed persons and in young children.

Diagnosis:
A medical history
a chest X-ray
A physical examination
Tuberculin skin test
microbiological smears and cultures.
The interpretation of the tuberculin skin test depends upon the person's risk
factors for infection and progression to TB disease, such as exposure to other
cases of TB or immunosuppressant
chest X-ray shows cavitating consolidation throughout the right upper lobe
with further areas of consolidation in the left upper andright lower lobes.
Chest X-ray of a patient with smear positive pulmonary tuberculosis showing
cavity in the left upper lobe
Mantoux test

Treatment:
Anti-tuberculosis drugs: It should be highly effective, free from side effects,
easy to administer, and reasonably cheap. The currently used drugs may be
classified into two groups: bactericidal and bacteriostatic.

Bactericidal drugs:
Rifampicin: 10-12mg/kg body weight
INH: single daily dose of 4-5 mg/kg body weight
Streptomycin: the daily dose is 0.75-1 gm in a single dose
Pyrazinamide: 30 mg/kg body weight divided into 2 or 3 doses per day or 45-
50 mg/kg body weight twice weekly

Bacteriostatic drugs:
Ethambutol: 15 mg/kg body weight in 2-3 doses per day. Its major side effect is
optic neuritis.
Thioacetazone: the usual adult dose is 2 mg/kg body weight. Side effects
include GI disturbance, blurring of vision, hemolytic anemia and urticaria.

First Line Drugs:
Rifampicin
Isoniazid
Ethambutol
Streptomycin
Pyrazinamide

Second Line Treatment:
Ethionamide
Ciprofloxacin/Ofloxacin
Cycloserine
Kanamycin
Para-aminosalicylic acid.

DOTS (Directly observed therapy, short course)
Patient swallows the medications under the watchful eye of a reliable person
doctors, nurse, health worker, community volunteer for the duration of 6-9
months.
By this method 100% cure of the patients is expected, if the patient takes the
drugs without fail.
It is free of cost in all health facilities working for the National TB control
program.
DOTS has five elements:
Political commitment with increased and sustained financing
case detection through quality-assured bacteriology, standardized
treatment with supervision and patient support
an effective drug supply and management system
monitoring and evaluation system, and impact measurement.

Prevention:
Protect your family and friends: If you have active TB, keep your germs to
yourself. It generally takes a few weeks of treatment with TB medications
before you're not contagious anymore. Follow these tips to help keep your
friends and family from getting sick:
Stay home.
Ventilate the room.
Cover your mouth.
Wear a mask.
Finish your entire course of medication: This is the most important step you
can take to protect yourself and others from tuberculosis. When you stop
treatment early or skip doses, TB bacteria have a chance to develop mutations
that allow them to survive the most potent TB drugs. The resulting drug-
resistant strains are much more deadly and difficult to treat.
Vaccinations: In countries where tuberculosis is more common, infants often
are vaccinated with bacille Calmette-Guerin (BCG) vaccine, It is living bacteria
derived frm an attenuated bovine strain of tubercle bacilli. because it can
prevent severe tuberculosis in children. The BCG vaccine isn't recommended
for general use in the United States because it isn't very effective in adults, and
it causes a false-positive result on a TB skin test.
given immediately after birth under EPI
Dosage: 0.1 mg given intradermally

Poliomyelitis:
is an acute infectious disease caused by a specific virus, and involving the nerve
cells of the spinal cord and medulla.
It is characterized by fever, headache, stiffness of neck and spine, weakness and a
flaccid paralysis of voluntary muscles develops within the first few days. in a
varying proportion of patients there remains some degree of permanent crippling
involvement of the respiratory mechanism, either in the medulla or spinal cord
may lead to respiratory failure, which is the usual cause of death in this disease.
Fatality rate is 4-15 % for bulbar poliomyelitis, 5-60 % it may be high.
Poliomyelitis is chiefly encountered in children between the ages of 1-12 years.
Infection prevails throughout the world either in sporadic form or epidemic form
at irregular intervals, the highest incidence is in summer and in early winter.
Diagnosis:
The virus may be isolated from faeces, or throat secretions.
Complement fixation tests show rising titre of antibodies to one type of virus.
To exclude other diseases, microscopic and chemical examinations of the
spinal fluid should be done.
Source of infection:
Oro-pharyngeal secretions and faeces of infected persons. In some instances
milk has been a vehicle of infection.
Causative agents:
Poliomyelitis virus (polio virus) are of 3 types; I, II, III, ( discovered by
Brunhilde, Lansing, and Leon respectively), all produce identical paralytic
disease, but in the lab these are unable to generate protective antibody
against one another.
It was once believed that poliovirus entered the human body by way of
olfactory neuroepithelium, but this has been disproved. It has not been
established that the mouth is the portal of entry, and that the route of
infection is via the lymphatic tissues of the alimentary canal (tonsils , payers
patches, deep cervical and mesenteric lymph nodes); later the virus appears in
the blood. These findings indicate that the central nervous system is invaded
from the blood rather than by nerve pathways.
The virus attacks certain type of nerve cells, the most seriously affected are
the motor neurons of the spinal cord. In severe disease the cells of the
immediate gray matter, posterior and dorsal root of ganglia may be involved.
Thalamus, motor, cortex and vestibulo- cerebellum may also be affected.
Incubation period: 7-21 days, commonly 12 days.
Period of communicability:
virus is usually present in the throat and faeces in late incubation period, and
first few days of acute illness. In the oro- pharynx the virus cannot be
demonstrated after 10-14 days of the illness; the virus persists in the faeces for
a much longer period.
Susceptibility ad resistance:
Susceptibility is general but very few develop paralytic disease. It is proved
that most human beings acquire immunity to poliomyelitis through sub-clinical
infections. Provoking factors to paralytic disease appear to be anything which
lowers resistance, prolonged chilling, disturbances of nutrition of metabolism,
pregnancy, tonsil-lectomy, adeniodectomy, fatigue or trauma.
Type-specific immunity is acquired by infection, second attacks are rare and
may be due to infection by virus of another type.
Methods of control:
Preventive environmental control of infected persons, contacts and
environment.
Notification: To local healthy authority.
Isolation: Pt. is isolated for 6 weeks from the date of onset of disease, and the
contacts are isolated for 3 weeks.
Concurrent disinfection Of oropharyngeal discharges, faeces and articles soiled
with them.
Quarantine: infective. Quarantine of family contacts may be done for 3 weeks.
Immunization: this is the only way of effectively controlling poliomyelitis.
Salk and his co-workers (1954) produced a formalin inactivated vaccine
containing all three virus types. The same year the effectiveness of this new
agent in preventing the paralytic poliomyelitis was demonstrated on 402,000
children, 6-8 years of age, each receiving three injections either of vaccine or
of virus free culture fluid. There was no case of induced poliomyelitis in any
vaccinated person. During the subsequent seasonal increase in disease,
paralytic cases were observed 5 times more in non vaccinated children than in
the vaccinated ones.
A new attenuated live virus vaccine has been developed in the USSR it is given
by mouth. There, up to 1961, about 170,000,000 persons under 21 years of
age has been given this vaccine orally with no reported ill effects and marked
reduction in the incidence of poliomyelitis.
The dose is 3 drops orally commencing at birth, at interval of 4 weeks for 3
months.

Treatment:
Use of respirators can be life saving if the respiratory mechanism is involved.
Good orthopedic care is essential, to reduce musculoskeletal impairment.
Rehabilitation of handicapped forms is an important component of treatment
plan.

Epidemic measures:
Isolation of all children with fever, till diagnosis is done.
Education in bed nursing and disinfection of discharges and excreta.
Mass immunization of vulnerable age groups.
Postponement of nose and throat operations.
Avoid violent exercise.

International measures:
Telegraphic notification to WHO.
Global Eradication:
WHO has initiated a global programme of polio eradication in the foreseeable
future, in which children under five are immunized. Some countries have
achieved success in this effort.

Diarrhoea:
Diarrhoea is defined as the passage of three or more loose or watery stools in a
24-hour period, a loose stool being one that would take the shape of a container.
Important pathogens:
Rotavirus
Enterotoxigenic Escherichia coli
Shigella
Campylobacter jejuni
Vibrio cholerae 01
Salmonella
Cryptosporidium

Epidemiology:
Agent factors: Rotavirus, bacterial pathogens include enterotoxigenic
escherichia coli, shigella, campylobacter jejuni, V. cholera, salmonella,
protozoal pathogens include cryptosporidium
Reservoir of infection: Man

Host factors: Diarrhoea is most common in children between 6 months and 2
years. Incidence is highest in age group 6-11 months, when weaning occurs,
due to declining level of maternal antibodies.
Diarrhoea is more common in persons with malnutrition.
Environmental factors: Bacterial diarrhoea occur more frequently during the
warm season, whereas viral diarrhoea is more common in winter season.

Faeco-oral route.

Types of diarrhea:
Acute watery diarrhea: diarrhoea that begins acutely, lasts less than 14 days
and involves the passage of frequent loose or watery stools without visible
blood. Vomiting may occur and fever may be present
Dysentery: diarrhea with visible blood in the faeces. Important effects of
dysentery include anorexia, rapid weight loss, and damage to the intestinal
mucosa by the invasive bacteria.
Persistent diarrhea: long duration (at least 14 days). The episode may begin
either as watery diarrhoea or as dysentery. Marked weight loss is frequent.
Diarrhoeal stool volume may also be great, with a risk of dehydration.

Symptoms:
Frequent, watery motions.

Loss of appetite.

Nausea, vomiting.

Stomach pains.

Fever.

Dehydration.

Control and treatment:
Oral rehydration therapy: can be safely used in treating acute diarrhoea.
Oral Rehydration Solution: ORS.
Constituents & the concentration m mol /liter:
Sodium= 75 , Potassium= 20 , chlorine= 65 , citrate= 10 , Glucose= 75.
Composition of world Health Organization.
The total fluid deficit in severely dehydrated patients (10% of body
weight) can be replaced safely within the first 4 hours of therapy, half
within the first hour.

Appropriate feeding: New born infants with diarrhoea who show little or no
signs of dehydration can be treated by breast feeding alone. Those with
moderate or severe dehydration should receive ORS, once the child is
rehydrated, breast feeding is continued along with ORS.
Antibiotics: Unnecessary prescription of the antibiotics and other drugs will do
more harm than good in the treatment of diarrhoea.

Prevention:
- improving access to clean water and safe sanitation
promoting hygiene education
- exclusive breast-feeding
- improved weaning practices
- immunizing all children; especially against measles
using latrines
- keeping food and water clean
- washing hands with soap (the baby's as well) before touching food
and by sanitary disposal of stools.

Cholera:
Cholera is an acute, diarrheal disease caused by Vibrio cholerae. The infection is
often mild or without symptoms, but sometimes it can be severe. Approximately
one in 20 infected persons has severe disease characterized by profuse watery
diarrhea, vomiting, and leg cramps,causing rapid loss of body fluids leads to
dehydration and shock. Without treatment, death can occur within hours.
Epidemiology:
Agent factors:
Agent: Vibrio cholera
Reservoir of infection: Human, may be as case or carrier
Infective material: Stools and vomit of cases and carriers
Period of communicability: 7-10 days
Host factors:
Age and sex: Cholera can affects all ages and both sexes
Economic status: High in low socio-economic groups, due to poor hygiene
Environmental factors: Poor environmental sanitation, includes contaminated
water and foods.

Transmission occurs from man to man through faecally contaminated water,
food and drinks.

Clinical features:
The onset is abrupt with profuse, painless, watery diarrhea followed by
vomiting, the person may pass as many as 40 stools in a day, which is rice
water appearance.
The person is dehydrated due to excess loss of water from the body, the
classical signs are sunken eyes, hollow cheeks, schapoid abdomen,
unrecordable BP, feeble pulse, fast respiration., decrease urine output, the
person becomes restless, and complains of intense thirst and cramps in legs
and abdomen. Death may occur due to dehydration.

Control and Treatment:
Verification of the diagnosis: Presence of V. cholera in stools
Cholera can be simply and successfully treated by immediate replacement of
the fluid and salts lost through diarrhea. Patients can be treated with oral
rehydration solution. This solution is used throughout the world to treat
diarrhea. Severe cases also require intravenous fluid replacement. With
prompt rehydration, fewer than 1% of cholera patients die.

Antibiotics shorten the course and diminish the severity of the illness, but they
are not as important as rehydration.

Prevention:
It is preventable if proper sanitation practices are followed.
Travelers should be aware of how the disease is transmitted and what can be
done to prevent it. Good sanitation practices, if instituted in time, are usually
sufficient to stop an epidemic. There are several points along the transmission
path at which the spread may be halted:
Proper disposal and treatment of the germ infected fecal waste produced by
cholera victims is of primary importance.
Treatment of general sewage before it enters the waterways or underground
water supplies prevents undiagnosed patients from spreading the disease.
Sources: Warnings about cholera contamination posted around contaminated
water sources with directions on how to decontaminate the water.
Sterilization: Boiling, filtering, and chlorination of water kill the bacteria
produced by cholera patients and prevent infections from spreading. All
materials that come in contact with cholera patients should be sterilized in hot
water using chlorine bleach .Hands that touch cholera patients or their
clothing and bedding should be thoroughly cleaned and sterilized. All water
used for drinking, washing, or cooking should be sterilized by boiling.

Food poisoning:
It is an acute gastro-enteritis caused by ingestion of contaminated food or
drink. Typical symptoms include nausea, vomiting, abdominal cramps, and
diarrhea that occur suddenly (within 48 hours) after consuming a
contaminated food or drink.
Types of food poisoning:
Non bacterial: Caused by chemicals such as arsenic, certain plant and sea
foods, poisonous mushrooms, or pesticides on fruits and vegetables.
Bacterial: Caused by the ingestion of foods contaminated by living bacteria and
their toxins

Types of bacterial food poisoning:

Salmonella Food Poisoning:
An extremely common form of food poisoning,Causative agent is
S.typhimurium, S. cholera
Source: is contaminated meat, milk, and milk products, egg, and egg products.
Incubation period: 12-24 hours
Mechanism of food poisoning: The causative organism, on ingestion, multiply
in the intestine and gives rise to acute enteritis and colitis. The onset is
generally sudden with chills, fever, nausea, vomiting, and a profuse watery
diarrhoea which usually lasts 2-3 days.
The illness is transmitted by undercooked foods such as eggs, poultry, dairy
products, and seafood.

Staphylococcal Food Poisoning:
It is about as common as salmonella food poisoning
Agent: Staphylococcus aureus
Source: Milk and milk products contaminated by staphylococci
Mechanism of food poisoning: It results from ingestion of toxins preformed in
the food in which bacteria have grown. The toxins act directly on the intestine
and CNS. There is sudden onset of vomiting, abdominal cramps and diarrhoea.
In several cases, blood and mucus may appear, rarely causes fever.
These bacteria produce a toxin in foods such as cream-filled cakes and pies,
salads and dairy products. Contaminated salads at picnics are common if the
food is not chilled properly.

Botulism Food Poisoning:
Most serious but rare.
Agent: Exotoxins of Clostridium botulism generally type A,B, or E.
Source: home preserved foods, such as home canned vegetables, pickeled fish,
home made cheese.
Mechanism of food poisoning: Toxins acts on the nervous system. The
prominent GI symptoms are very slight, such as dysphagia, diplopia, ptosis,
dysarthria, blurring of vision, muscle weakness and even quadriplegia.
The condition is frequently fatal, death occurring 4-8 days later due to
respiratory or cardiac failure

Cl. Perfringens Food Poisoning:
Agent: Cl perfringens(welchi)
Source: Faeces of human and animals, and in soil, water and air
Incubation period: 6-24 hours, with a peak of 10-14 hours
Mechanism of food poisoning: The organism multiply between 30-50 deg. C
and produce a variety of toxins.
The most common symptoms are diarrhoea, abdominal cramps and little or no
fever, occuring 8-24 hours after consumption of short duration, usually 1 day
or less.

Cereus Food Poisoning:
Bacillus cereus is an aerobic, spore-bearing, motile, gram positive rod.
With short incubation period(1-6 hours) characterized by predominantly upper
GI symptoms, like sudden onset of vomiting, abdominal cramps and diarrhoea.
The other diarrhoeal form, with longer incubation period(12-24 hours)
characterized by predominantly lower intestinal tract symptoms like ,
diarrhoea, abdominal pain, nausea with little or no vomiting and no fever.
Recovery within 24 hours is usual. The toxins are preformed and stable.

Differential diagnosis:
Food poisoning may be mistaken for cholera, acute bacillary dysentery and
chemical (arsenic) poisoning.

Diagnosis:
From history
Thorough examination will be performed, including measurements of blood
pressure, pulse, breathing rate, and temperature.
Assessment of dehydration.
Blood tests may be performed to determine the seriousness of the illness.

Treatment:
Short episodes of vomiting and small amounts of diarrhea lasting less than 24
hours can usually be cared at home.
Avoid solid food in nausea or vomiting but drink plenty of fluids, small,
frequent sips of clear liquids to prevent dehydration.
The main treatment for food poisoning is to rehydrate through ORS or by an IV
fluids. The patient may need to be admitted to the hospital. This depends on
the severity of the dehydration, response to therapy, and ability to drink fluids
without vomiting.
Anti-vomiting and diarrhea medications may be given.

Prevention:
Safe steps in food handling, cooking, and storage are essential to avoid food-
borne illness.
Food sanitation: which includes
i. meat inspection,
ii. personal hygiene should be maintained during preparing and cooking food,
iii. food handlers
iv. food handling techniques
v. sanitary improvement:
vi. health education:.
Refrigeration:
Safe food preparation:
Continuous surveillance of food samples is necessary to avoid outbreaks of
food-borne diseases.

Amoebiasis:
The condition of harbouring the protozoan parasite Entamoeba Histolytica with
or without clinical manifestation.
About 90% of infections are asymptomatic and the remaining 10% produce a
spectrum of clinical syndromes ranging from dysentery to abscesses of the liver or
other organs.
Gradual onset of abdominal pain and diarrohea.
Abdominal exam may show distention, tenderness, hyperperistalsis and
hepatomegally.
Humans are the only established E.histolytica host.

occurs through ingestion of cysts from focally contaminated food or water,
facilitated by person to person spread, flies and use of human excreta as
fertilizer.
Urban outbreak have occurred because of common source water
contamination.
80% of children had atleast 1 episode of infection with E.histolytica and 53%
had more than 1 episode.

Drugs:
Asymptomatic: Luminal agent: Iodoquinol (650 mg tablets), 650 mg tid for 20
days, or paromomycin (250 mg tab.), 500mg tid for 10 days.
Acute collitis: Metronidazole(250 or 500 mg tab.), 750 mg PO or IV tid for 5-10
days plus luminal agent as above.
Amebic Liver Abscess: Metronidazole 750mg PO or IV for 5-14 days. Or
Tinidazole 2g per oral once, or Ornidazole 2 g PO once plus luminal agent as
above.

Prevention:
An asymptomatic carrier may excrete up to 15 million cysts per day so
prevention requires;
Safe water supplies,
Sanitary disposal of human feces,
Adequate cooking of foods,
Protection of food from fly contamination,
hand washing, and in endemic areas, avoidance of foods that can not be
cooked or .
Water supplies can be boiled, treated with iodine( 0.5 ml tincture of iodine per
lite3r for 20 mins, cysts are resistant to standard concentrations of chlorine) or
filtered.

Ascariasis:
Asc.Lumbricoid is the largest intestinal nematode parasite of humans, reaching up
to 40cm in length. Most infected individuals have low worm hurdens and are
asymptomatic.
Clinical disease arise from larval migration in the lungs or effects of the adult
worm in the intestine.
EPIDEMIOLOGY:
Ascaris is widely distributed in tropical and subtropical regions as well as in
other humid areas.
typically occurs through focally contaminated soil and is due to a lack of
sanitary facilities or due to the use of human feces as fertilizer.
Younger children are most infected.
Infection outside endemic areas, though uncommon, can occur when eggs on
transported vegetables are ingested.

Treatment:
Albendazole( 400mg once) , mebendazole(500mg once) or ivermectin(150-
200g/kg once) is effective.
The medications are contraindicated during pregnancy.
Pyrantel pamoate(11mg/kg once) is safe in pregnancy.

Hepatitis B:
Hepatitis means inflammation of the liver.
So, Hepatitis B is the inflammation of the liver by a virus that attacks the liver.
Hepatitis B is caused by a virus called Hepatitis- B virus.
Epidemiology:
Agent factors:
Agent: Hepatitis B virus is a complex, 42-nm, double-shelled DNA virus.
Reservoir of infection: Man is only reservoir of the infection which can be
spread either from carriers or from cases.
Infective material: Contaminated blood is the main source of infection,
although the virus has been found in the body secretions such as saliva, vaginal
secretions, and semen of infected persons.
Incubation period: Several months to years

Host factors
Age: Among the age group 20-40 years, where HBV is relatively uncommon,
and in perinatally or during early childhood where infection with HBV is
common

Unsafe blood transfusion
Sharing drug needles
Having sex with an infected person
Having a tattoo or body piercing (ear, acupuncture ) done with dirty tools that
were used on someone else
Getting pricked with a needle that has infected blood on it (health care
workers can get hepatitis B this way)
Sharing a toothbrush or razor with an infected person
Perinatally from a chronically infected mother to her infant, at the time of
delivery.

Risk groups:
Injecting drug users
Persons with multiple sex partners
Sex contacts with an infected persons
Household contacts of chronically infected persons
Infants born to infected mother
Health care and public safety workers
Hemodialysis patients (or people who use a kidney machine)
Travel to areas where hepatitis B is common

Signs and symptoms:
fatigue
fever
loss of appetite - anorexia
stomach pain, stomach upset
diarrhea
Vomiting
Muscle and joint pain
dark yellow urine
light-colored stools
yellowish eyes and skin

Treatment:
Acute hepatitis needs no treatment other than careful monitoring of liver
function, by measuring serum transaminases and prothrombin time.
In rare cases of liver failure, the patient should be monitored in an intensive
care unit.
lactulose, metronidazole should be administered (to limit protein production
by bacteria in the gut).
Treatment of chronic hepatitis to reduce inflammation, symptoms, and
infectivity. Treatment options include interferon as well as lamivudine.
Liver transplantation is used to treat end-stage chronic hepatitis B liver
disease.

Prevention:
Screening of all donated blood has reduced the likelihood of contracting
hepatitis B from a blood transfusion.
Sexual contact with a person who has acute or chronic hepatitis B should be
avoided.
Immunization provides the only definitive protection against the virus.
Vaccination of those at high risk has been of only limited success.
Therefore,universal vaccination of all newborns and pre-pubertal teenagers
has recommended.
Infants born of mothers who have acute hepatitis B need to be administered
hepatitis B immune globulin and a hepatitis B immunization within 12 hours of
birth.

Hookworm Infection:
Two hookworm species (A. duodenale and N. americanus) Most infected
individuals are asymptomatic.

Clinical Features:
Most hookworm infections are asymptomatic.
Infective larvae may provoke pruritic maculopapular dermatitis ("ground
itch") at the site of skin penetration.
Larvae migrating through the lungs occasionally cause mild transient
pneumonitis, but this condition develops less frequently in hookworm
infection than in ascariasis.
In the early intestinal phase, infected persons may develop epigastric pain
(often with postprandial accentuation), inflammatory diarrhea, or other
abdominal symptoms accompanied by eosinophilia.
The major consequence of chronic hookworm infection is iron deficiency.
Symptoms are minimal if iron intake is adequate, but marginally
nourished individuals develop symptoms of progressive iron-deficiency
anemia and hypoproteinemia, including weakness and shortness of
breath.

Treatment:
Albendazole (400 mg once), mebendazole (500 mg once), and pyrantel
pamoate (11 mg/kg for 3 days).
Mild iron-deficiency anemia can often be treated with oral iron alone.
Severe hookworm disease with protein loss and malabsorption necessitates
nutritional support and oral iron replacement along with deworming

Prevention:
Sanitation, hygiene
Do not walk barefoot
Do not defecate outside latrines, toilets etc.
Do not use human excrement or raw sewage as manure/fertilizer in agriculture

Typhoid Fever
Typhoid fever is a bacterial disease, caused by Salmonella typhi. It is transmitted
through the ingestion of food or drink contaminated by the faeces or urine of
infected people.
Causes:
Typhoid fever is caused by a virulent bacterium called Salmonella typhi.
Although they're related, this isn't the same as the bacteria responsible for
salmonellosis, another serious intestinal infection.

Risk factors:
Work in or travel to areas where typhoid fever is endemic
Have close contact with someone who is infected or has recently been infected
with typhoid fever
Have an immune system weakened by medications such as corticosteroids or
diseases such as HIV/AIDS
Drink water contaminated by sewage that contains S. typhi.

Clinical feature:
Fever, often as high as 103 or 104 F (39 or 40 C)
Headache
Weakness and fatigue
A sore throat
Abdominal pain
Diarrhea or constipation
Rash

Management:
Bed rest
Drinking fluids and take healthy food
NSAIDs
H2 blocker
Antibiotics-
1.ciprofloxacin(500mg) 12 hrly for 14 days
2.cotrimoxazole(960mg) 12 hrly for 14 days
3.amoxycillin(750mg) 6 hrly for 14 days

Prevention:
In many developing nations, the public health goals that can help prevent and
control typhoid safe drinking water, improved sanitation and adequate
medical care may be difficult to achieve. For that reason, some experts
believe that vaccinating high-risk populations is the best way to control
typhoid fever.

Rabies:
Rabies is an acute highly fatal viral disease of CNS.
Rabies is also known as hydrophobia.
It is transmitted to people from infected mammals.
Rabies can be prevented by avoiding exposure to infected animals.
Rabies is preventable through a series of vaccination after exposure , but it is fatal
once symptoms appear.

Epidemiology:
Agent: The rabies virus is an RNA virus belongs to family rhabdo viridae,
commonly have cubic symmetry and biopsy shows typical negri bodies in the
infected neurons.
Reservoir infection: Animals (cats, dogs, rabbits, fox, bats) in America.
Source of infection: Saliva of the rabid animal.
Host factors: All warm blooded animals included man are susceptible to rabies.
(rabies free-UK,TAIWAN,IRELAND).
(one dog spread this to 40-60/cm areas).

An infected animal carries the rabies virus in its saliva and can transmit to a
person through biting.
After a bite , the rabies virus (lysa virus )can spread into the persons
surrounding muscles, then travel up a nearly nerve to brain. Once the virus
infects the brain it can cause severe possibility permanent injury.

Incubation period:
The incubation period in man is highly variable usually 3-8wks following
exposure but may vary from 4 days to many years. It depends upon site of
bites , number of wounds, species of biting animals.

Infective period:
5 days before the onset of symptoms to death of animals.

Clinical feature:
Rabies in man causes hydrophobia. The disease begins with prodromal
symptoms such as headache, malaise , sore throat and slight fever lasting for
3-4 days.
Pain and tingling at the site of bite.
Typically, people with rabies develop irregular contra indications and spasm of
breathing muscles when exposed to water (hydrophobia).
Weakness or paralysis.
Extreme sensitivity to bright light, sound and touch.
Increased production of saliva causing the foaming at the mouth or tears.
Difficulty in speaking because (larynx, pharynx contracted spasm).

Diagnosis:
A clinical diagnosis of hydrophobia can be made on the bases of history of
bites of a rabid animal, characteristic sign and symptoms.

Examination:
Vital sign will be taken (temp, heart rate, breathing rate and BP).
Rabies can be confirmed in patients early in the illness by antigen detection
causing immunofluorescence of skin biopsy and by virus isolation from saliva
and other secretions.
After or on 8
th
day antigen antibody detection, decreased protein level.

Treatment:
There is no specific treatment for rabies.
Care of wound immediately by washing with soap, water and antiseptic iodine
solution. This will kill the bacterial germs and decreased the transmission of
the rabies virus.
The patient should be isolated in a quite room.
Sedatives to relieve anxiety and pain.
Muscle relaxant in spasmatic muscular contraction.
Intestine therapy in the form of respiratory and cardiac support may be given.
Both human rabies immunoglobulin (HRIG) and the various vaccines are safe in
pregnancy.

Pre-exposure prophylaxis:
Pre-exposure vaccination is recommended for person in high risk groups, such
as veterinarians, animal, handless, and certain laboratory workers.
People who are working with rabies live virus in research laboratories or
vaccine production facilities are at the highest risk of in apparent exposure
such as person should have a serum (blood) sample tested for antibody every
6 months and receive booster vaccine, when necessary.
Pre-exposure prophylaxis consist of rabies vaccine given on days 0,7,21 or 28.

Prevention:
Prevention of rabies depends upon decreasing the disease in the animal.
Avoid contact with wild animal and strays. vaccine pets against rabies, keep
pets under control and away from mild animals from strays.
(booster dose-90
th
day)

Vaccines for Immunization:
Human diploid cell vaccine.
In activated sleep brain vaccine.
Purified chick embryo cell culture vaccine.
If given properly and on schedule only of these three type will give protection
against the rabies.

Plague:
It is a severe and potentially deadly bacterial infection. It is a primarily and
basically a zoonotic disease caused by yersinia pestis, involving rodents and fleas,
transmitted by the bite of infected flea to human.
Three most common forms:
1)Bubonic plague is an infection of the lymph nodes.
2)Pneumonic plague is an infection of lungs.
3)Septicemic plague is an infection of blood.

Epidemiological factors:
Agent factors: Y.Pestis gram negative bacteria, non motile, cocco-bacillus.
Reservoir: Wild rodents (field mice and other small animals are the natural
reservoir of plague).
Source of infection: Infected rodents, fleas and cases of pneumonic plague.
Host factors: All ages and both sexes are susceptible.
Environmental factor: Sep to May.
Temperature: 20-25C and humidity of 60% and above.
Dwelling: Poor housing condition favors the rat and rat flea.
Vector: Rat flea.

Bite of infected flea.
Direct contact with the tissue of the infected animals.
Droplet infection from the cases of pneumonic plague.

Incubation period:
Bubonic plague:- 2-7 days
Pneumonic plague:- 1-3 days
Septicemic plague:- 2-7 days

Clinical Features:
Bubonic plague: Most common(90%). Onset is acute with high
fever,chills,headache,myalgia,nausea, vomiting,and painfull
lymphadenitis,seizures.
Greatly enlarged tender lymph nodes, in groin and less often in the axilla or
neck are the most commonly affected. pain may occur in the area by swelling.
Pneumonic plague: Symptoms appear suddenly, typically 2-3 days after
exposure. they include severe cough, frothy, blood, sputum, difficulty in
breathing.
Rare(1%). It is highly infectious and spreads from man to man by droplet
infection. Often death within 1-3 days.
100% mortality if untreated CXR shows bilateral infiltrates.

Septicemic Plague: May causes death even before the symptoms occur.
Symptoms can include sudden high fever, abdominal pain, blood clotting
problems, diarrhea, low B.P, nausea, organ failure, vomiting.

Prevention and control:
Control of cases: Early diagnosis and treatment.
Notification: Standard isolation for 1
st
72 hrs.
Hand washing, gloves, gowns, face masks, eye protection, surgical masks for
patients.
Control of fleas: Spraying insecticides e.g; DDT,BHC.
Control of rodents: Mass destruction of rodents. Improvement of general
sanitation, housing quality of life, health education.

Treatment:
Streptomycin 30-40 mg/kg body weight IV for 7-10 days.
Tetracyclin 40mg/kg.
Multi vitamins.
Antiboitics (ciprofloxacin 7 days). Oxygen, intra venous fluid and respiratory
sports are usually needed.

Brucellosis:
is an infectious disease that spreads from animals to people most often via
unpasteurized milk, cheese and other dairy products. More rarely, the bacteria
that cause brucellosis can spread through the air or through direct contact with
infected animals.
Brucellosis symptoms include fever, joint pain and fatigue. The infection can
usually be treated successfully with antibiotics. Treatment takes several weeks,
however, and relapses are common.
Occupations at higher risk:
People who work with animals or come into contact with infected blood are at
higher risk of brucellosis. Examples include:
Veterinarians
Dairy farmers
Ranchers
Slaughterhouse workers
Hunters
Microbiologists

Prevention:
To reduce the risk of getting brucellosis, take these precautions:
Avoid unpasteurized dairy foods.
Cook meat thoroughly
Wear gloves
Take safety precautions in high-risk workplaces
Vaccinate domestic animals.

Toxoplasmosis:
is a disease that results from infection with the Toxoplasma gondii parasite. This
organism is one of the world's most common parasites.
Toxoplasmosis may cause flu-like symptoms in some people, but most people
affected never develop signs and symptoms. For infants born to infected mothers
and for people with weakened immune systems, toxoplasmosis can cause
extremely serious complications.
If you're generally healthy, you probably won't need any treatment for
toxoplasmosis. If you're pregnant or have lowered immunity, certain medications
can help reduce the infection's severity. The best approach, though, is prevention.
Treatments and drugs:
Pyrimethamine (Daraprim).
Sulfadiazine
Treating people with HIV/AIDS: If you have HIV/AIDS, the treatment of choice
for toxoplasmosis is also pyrimethamine and sulfadiazine, along with folic
acid.

Prevention:
Certain precautions can help prevent toxoplasmosis:
Don't eat raw or undercooked meat.
Wear gloves when you garden or handle soil
Wash kitchen utensils thoroughly.
Wash all fruits and vegetables.
Don't drink unpasteurized milk.
Cover children's sandboxes

Leishmaniasis:
is a disease caused by protozoan parasites that belong to the genus ''Leishmania''
and is transmitted by the bite of certain species of sand fly (subfamily
Phlebotominae).
Types:
Cutaneous leishmaniasis is the most common form of leishmaniasis. Visceral
leishmaniasis is a severe form in which the parasites have migrated to the vital
organs.

Most forms of the disease are transmissible only from animals (zoonosis), but
some can be spread between humans.

Symptoms:
The symptoms of leishmaniasis are skin sores which erupt weeks to months
after the person affected is bitten by sand flies. Other consequences, which
can become manifest anywhere from a few months to years after infection,
include fever, damage tothe spleen and liver, and anaemia.

Prevention:
There are no vaccines to prevent leishmaniasis. The best way to protect
yourself from the disease is to avoid being bitten by sand flies by staying
indoors from dusk to dawn. When the insects are the most active; wearing
long pants and long sleeved shirts when outside; and using insect repellent
and bed nets as needed.

Scabies:
is an itchy skin condition caused by a tiny burrowing mite called Sarcoptes scabiei.
The presence of the mite leads to intense itching in the area of its burrows. The
urge to scratch may be especially strong at night.
Scabies is contagious and can spread quickly through close physical contact in a
family, child care group, school class or nursing home. Because of the contagious
nature of scabies, doctors often recommend treatment for entire families or
contact groups to eliminate the mite.
Medications applied to your skin kill the mites that cause scabies and their eggs,
although you may still experience some itching for several weeks.

Treatment and Drugs:
Medications commonly prescribed for scabies include:
Permethrin 5 percent (Elimite)
Lindane
Crotamiton (Eurax).
Itching may persist for some time after you apply medication to kill the mites.
These steps may help you find relief from itching:
Cool and soak your skin. Soaking in cool water or applying a cool, wet
washcloth to irritated areas of your skin may minimize itching.
Apply soothing lotion. Calamine lotion, available without a prescription, can
effectively relieve the pain and itching of minor skin irritations.
Take antihistamines. At your doctor's suggestion, you may find that over-the-
counter antihistamines relieve the allergic symptoms caused by scabies.

Prevention:
To prevent re-infestation and to prevent the mites from spreading to other
people, take these steps:
Clean all clothes and linen. Use hot, soapy water to wash all clothing, towels
and bedding you used at least three days before treatment. Dry with high
heat. Dry-clean items you can't wash at home.
Starve the mites. Consider placing items you can't wash in a sealed plastic bag
and leaving it in an out-of-the-way place, such as in your garage, for a couple
of weeks. Mites die if they don't eat for a week

TRACHOMA:
Trachoma is a bacterial infection that affects your eyes. The bacterium that
causes trachoma spreads through direct contact with the eyes, eyelids, and nose
or throat secretions of infected people.
Trachoma is very contagious and almost always affects both eyes. Signs and
symptoms of trachoma begin with mild itching and irritation of your eyes and
eyelids and lead to blurred vision and eye pain. Untreated trachoma can lead to
blindness.
Trachoma is the leading preventable cause of blindness worldwide.

Epidemiological Features:
Agent Factors:
Agent: Trachoma is caused by bacteria Chlamydia Trachomatis, sero type A,B
or C.
Reservoir: Children with active disease chronically infected older children and
adults.
Source of infection: Ocular discharges of the infected person and the fomites.

Host Factors:
Age: In endemic areas, children may show the sign of this disease at the age of
only a few months but children aged 2-5 years are most infected.
Sex: Females have been found to be more affected than males.
Predisposing factors: Direct sunlight, dust, smoke and irritant.

Environmental factors:
Trachoma is associated with poor quality of life, ignorance, poor personal
hygiene, illiteracy and poor housing.

Primary: Person to person transmission by ocular discharge. It is spread by
direct contact with ocular discharges of infected person or fomites e.g,
infected fingers, towels.
Secondary: Insect vector such as house fly. The discharge from infected eyes
attract flies that land on other peoples skin.
Incubation period: 5-12 days.

Treatment:
Medications: In the early stages of trachoma, treatment with antibiotics alone
may be enough to eliminate the infection. The two drugs currently in use
include a tetracycline eye ointment and oral azithromycin (Zithromax).

Surgical correction: The scaring and visual change for trachoma can be
reversed by a simple surgical procedure performed at village level which
reverses the in turned eyelashes.
As a part of global elimination of trachoma by 2020 program is providing
antibiotics to treat trachoma as part of its SAFE strategy to tackle the
infection.
SAFE:
(Surgery, Antibiotics, Facial cleanliness, Environmental change).

Prevention:
If you're traveling to parts of the world where trachoma is common, be sure to
practice good hygiene to prevent infection.
If you've been treated for trachoma with antibiotics or surgery, reinfection is
always a concern. For your protection and for the safety of others, be sure that
family members or others you live with are screened and, if necessary, treated
for trachoma.
Proper hygiene practices include:
Face washing and hand-washing. Keeping faces clean, especially children's, can
help break the cycle of reinfection.
Controlling flies. Reducing fly populations can help eliminate a major source of
transmission.
Proper waste management. Properly disposing of animal and human waste
can reduce breeding grounds for flies.
Improved access to water. Having a fresh water source nearby can help
improve hygienic conditions.

Leprosy:
Leprosy is a chronic infectious disease caused by Mycobacterium leprae.
It affects mainly the peripheral nerves, also the skin, muscles, eyes, bones and
testes.
Leprosy is also called Hansens disease.
Leprosy is clinically characterized by:
hypo pigmented patches
Partial or total loss of cutenous sensation in the affected areas.
Presence of thickened nerves.

Epidemiological features:
Agent: M. leprae, they are acid fast bacilli and occur in human host both
intracellularly and extracelluraly.
Source of infection: multi bacillary cases
Portal of exit: Nose is the major portal of exit.
Infectivity: It is highly infectious disease
Age: Incidence rates generally rise to a peak between 10 and 20 years of age.
Sex: More in males than in females
Environmental Factors: Humidity favors the survival of M. leprae in the
environment, overcrowding and lack of ventilation within households.
Social factors: Poverty, overcrowding, poor housing, lack of education, lack of
personal hygiene

In humans, direct skin to skin contact may transmit leprosy, but the naso
respiratory route is the most common.
Secretions from the nasal mucosa of untreated lepromatous patient contain
large number of viable leprosy bacilli. Transmission through mothers milk or
transplacental transmission is possible.

Risk groups:
At highest risk are those living in endemic areas with poor conditions such as
inadequate bedding, contaminated water and insufficient diet, or other
diseases (such as HIV) that compromise immune function.

Clinical features:
Loss of sensation to pain and temperature. People with peripheral nerve
damage may unknowingly burn, cut, or otherwise harm themselves.
Skin infection can lead
to areas of swelling
and lumps, which
can be particularly
disfiguring on the face.
Repeated damage may eventually lead to loss of fingers and toes. Also,
damage to peripheral nerves may cause muscle weakness, at times resulting in
clawing of the fingers and a "drop foot" deformity
People with leprosy also may develop sores on the soles of the feet.
Damage to the nasal passages can result in a chronically stuffy nose and, if
untreated, complete erosion of the nose.
Eye damage may lead to blindness.
Men with lepromatous leprosy may have erectile dysfunction (impotence) and
become infertile.

Treatment:
Leprosy is a curable disease and treatment provided in the early stages averts
disability;
With minimal training, leprosy can be easily diagnosed on clinical signs alone;
A World Health Organization (WHO) Study Group recommended multidrug
therapy (MDT) in 1981. MDT consists of three drugs: dapsone, rifampicin and
clofazimine. This drug combination kills the pathogen and cures the patient;
MDT is safe, effective and easily administered. MDT is available in convenient
monthly calendar blister packs to all patients;

Prevention & Control:
The best way to prevent the spread of leprosy is the early diagnosis and
treatment of people who are infected. For household contacts, immediate and
annual examinations are recommended for at least five years after last contact
with a person who is infectious.
The number of contagious patients should be reduced by chemotherapy.
The surveillance of contacts will detect early leprosy.

AIDS:
AIDS is a chronic, potentially life-threatening condition caused by the human
immunodeficiency virus (HIV). By damaging your immune system, HIV interferes
with your body's ability to fight the organisms that cause disease.
HIV is a sexually transmitted infection. It can also be spread by contact with
infected blood, or from mother to child during pregnancy, childbirth or breast-
feeding. It can take years before HIV weakens your immune system to the point
that you have AIDS.
There's no cure for HIV/AIDS, but there are medications that can dramatically
slow the progression of the disease. These drugs have reduced AIDS deaths in
many developed nations. But HIV continues to decimate populations in Africa,
Haiti and parts of Asia.
Treatments and drugs:
There's no cure for HIV/AIDS, but a variety of drugs can be used in
combination to control the virus. Each of the classes of anti-HIV drugs blocks
the virus in different ways. It's best to combine at least three drugs from two
different classes to avoid creating strains of HIV that are immune to single
drugs. The classes of anti-HIV drugs include:
Non-nucleoside reverse transcriptase inhibitors (NNRTIs). NNRTIs disable a
protein needed by HIV to make copies of itself. Examples include efavirenz
(Sustiva), etravirine (Intelence) and nevirapine (Viramune).
Nucleoside reverse transcriptase inhibitors (NRTIs). NRTIs are faulty versions
of building blocks that HIV needs to make copies of itself. Examples include
Abacavir (Ziagen), and the combination drugs emtricitabine and tenofovir
(Truvada), and lamivudine and zidovudine (Combivir).
Protease inhibitors (PIs). PIs disable protease, another protein that HIV needs
to make copies of itself. Examples include atazanavir (Reyataz), darunavir
(Prezista), fosamprenavir (Lexiva) and ritonavir (Norvir).
Entry or fusion inhibitors. These drugs block HIV's entry into CD4 cells.
Examples include enfuvirtide (Fuzeon) and maraviroc (Selzentry).
Integrase inhibitors. Raltegravir (Isentress) works by disabling integrase, a
protein that HIV uses to insert its genetic material into CD4 cells.

When to start treatment?
Current guidelines indicate that treatment should begin if:
You have severe symptoms
Your CD4 count is under 500
You're pregnant
You have HIV-related kidney disease
You're being treated for hepatitis B

Prevention:
There's no vaccine to prevent HIV infection and no cure for AIDS. But it's
possible to protect yourself and others from infection. That means educating
yourself about HIV and avoiding any behavior that allows HIV-infected fluids
blood, semen, vaginal secretions and breast milk into your body.
To help prevent the spread of HIV:
Use a new condom every time you have sex.
Consider the drug Truvada.
Tell your sexual partners if you have HIV.
Use a clean needle,
If you're pregnant, get medical care right away.
Consider male circumcision.

Syphillis:
Syphilis is a bacterial infection usually spread by sexual contact. The disease starts
as a painless sore typically on your genitals, rectum or mouth. Syphilis spreads
from person to person via skin or mucous membrane contact with these sores.
After the initial infection, the syphilis bacteria can lie dormant in your body for
decades before becoming active again. Early syphilis can be cured, sometimes
with a single injection of penicillin. Without treatment, syphilis can severely
damage your heart, brain or other organs, and can be life-threatening.
The cause of syphilis is a bacterium called Treponema pallidum. The most
common route of transmission is through contact with an infected person's sore
during sexual activity. The bacteria enter your body through minor cuts or
abrasions in your skin or mucous membranes.

Treatment:
When diagnosed and treated in its early stages, syphilis is easy to cure. The
preferred treatment at all stages is penicillin, an antibiotic medication that can
kill the organism that causes syphilis
After you're treated for syphilis, you should:
Have periodic blood tests and exams to make sure you're responding to the
usual dosage of penicillin.
Avoid sexual contact until the treatment is completed and blood tests indicate
the infection has been cured.
Notify your sex partners so that they can be tested and get treatment if
necessary.
Be tested for HIV infection.

Prevention:
To help prevent the spread of syphilis, follow these suggestions:
Abstain or be monogamous. The only certain way to avoid syphilis is to forgo
having sex. The next-best option is to have mutually monogamous sex with
one partner who is uninfected.
Use a latex condom. Condoms can reduce your risk of contracting syphilis, but
only if the condom covers the syphilis sores.
Avoid recreational drugs. Excessive use of alcohol or other drugs can cloud
your judgment and lead to unsafe sexual practices.
Screening for pregnant women
People can be infected with syphilis and not know it. In light of the often
deadly effects syphilis can have on unborn children, health officials
recommend that all pregnant women be screened for the disease.

Sexually Transmitted Diseases (STDs):

Sexually transmitted diseases (STDs), or sexually transmitted infections (STIs), are
generally acquired by sexual contact. The organisms that cause sexually
transmitted diseases may pass from person to person in blood, semen, or vaginal
and other bodily fluids.
Some such infections can also be transmitted nonsexually, such as from mother to
infant during pregnancy or childbirth, or through blood transfusions or shared
needles.
It's possible to contract sexually transmitted diseases from people who seem
perfectly healthy people who, in fact, aren't even aware of being infected.
Many STDs cause no symptoms in some people, which is one of the reasons
experts prefer the term "sexually transmitted infections" to "sexually transmitted
diseases."
Causes:
Sexually transmitted infections can be caused by:
Bacteria (gonorrhea, syphilis, chlamydia)
Parasites (trichomoniasis)
Viruses (human papillomavirus, genital herpes, HIV)
Sexual activity plays a role in spreading many other infectious agents, although
it's possible to be infected without sexual contact. Examples include the
hepatitis A, B and C viruses, shigella, cryptosporidium and Giardia lamblia.

Prevention:
There are several ways to avoid or reduce your risk of sexually transmitted
infections.
Abstain. The most effective way to avoid STIs is to abstain from sex.
Stay with 1 uninfected partner. Another reliable way of avoiding STIs is to stay
in a long-term mutually monogamous relationship with a partner who isn't
infected.
Get vaccinated. Getting vaccinated early, before sexual exposure, is also
effective in preventing certain types of STIs. Vaccines are available to prevent
two viral STIs that can cause cancer human papillomavirus (HPV), hepatitis
A and hepatitis B. The Centers for Disease Control and Prevention (CDC)
recommends the HPV vaccine for girls and boys ages 11 and 12. If not fully
vaccinated at ages 11 and 12, the CDC recommends that girls and women
through age 26 and boys and men through age 26 receive the vaccine. The
hepatitis B vaccine is usually given to newborns.
Wait and verify. Avoid vaginal and anal intercourse with new partners until
you have both been tested for STIs. Oral sex is less risky, but use a latex
condom or dental dam a thin, square piece of rubber made with latex or
silicone to prevent direct contact between the oral and genital mucous
membranes. Keep in mind that human papillomavirus (HPV) screening isn't
available for men, and no good screening test exists for genital herpes, so you
may not be aware you're infected until you have symptoms. It's also possible
to be infected with an STI yet still test negative.
Use condoms and dental dams consistently and correctly. Use a new latex
condom or dental dam for each sex act, whether oral, vaginal or anal. Never
use an oil-based lubricant, such as petroleum jelly, with a latex condom or
dental dam. Keep in mind that while condoms reduce your risk of exposure to
most STIs, they provide a lesser degree of protection for STIs involving exposed
genital sores, such as human papillomavirus (HPV) or herpes. Also, nonbarrier
forms of contraception, such as oral contraceptives or intrauterine devices,
don't protect against STIs.
Don't drink alcohol excessively or use drugs. If you're under the influence,
you're more likely to take sexual risks.
Avoid anonymous, casual sex. Don't look for sex partners online or in bars or
other pickup places. Not knowing your sex partner well increases your risk of
possible exposure to an STI.
Communicate. Before any serious sexual contact, communicate with your
partner about practicing safer sex. Reach an explicit agreement about what
activities will and won't be OK.
Teach your child. Becoming sexually active at a young age tends to increase a
person's number of overall partners and, as a result, his or her risk of STIs.
Biologically, young girls are more susceptible to infection. While you can't
control your teen or preteen's actions, you can help your child understand the
risks of sexual activity and that it's OK to wait to have sex.
Consider male circumcision. There's evidence that male circumcision can help
reduce a man's risk of acquiring HIV from an infected woman (heterosexual
transmission) by 50 to 60 percent. Male circumcision may also help prevent
transmission of genital HPV and genital herpes.
Consider the drug Truvada. In July 2012, the Food and Drug Administration
(FDA) approved the use of the drug Truvada (a fixed dose combination of
emtricitabine/tenofovir disoproxil fumarate) to reduce the risk of sexually
transmitted HIV infection in those who are at high risk. Truvada is also used as
an HIV treatment along with other medications.
When used to help prevent HIV infection, Truvada is only appropriate if your
doctor is certain you don't already have an HIV or hepatitis B infection. The
drug must also be taken daily, exactly as prescribed. And it should only be used
along with other prevention strategies such as condom use every time you
have sex.
Truvada isn't for everyone. If you're interested in Truvada, talk with your
doctor about the potential risks and benefits and whether it's right for you.

Tetanus:
Tetanus is a condition that affects the nervous system and causes painful,
uncontrolled muscle spasm also called lock jaw.
Tetanus is caused by a toxin produced by spores of the bacterium CLOSTRIDIUM
TETANI.
Tetanus spores are found usually in soil, dust and animal waste. It favors
anaerobic condition.
Tetanus is not contagious from person to person and is the only vaccine
preventable disease.
Epidemiology:
Agent factors:
Agent: Clostridium tetani is a gram +ve , anaerobic , spore bearing organism.
They germinate under anaerobic conditions and produces a potent exotoxin.
Reservoir: The natural habitat of the organism is soil and dust.
Host factors:
Age: All ages.
Sex: Higher incidence is found in females, but males appears to be more
sensitive to tetanus toxin than the females.
Occupational:
Agricultural workers are at high special risk of their contact with soil. In
Pakistan (Punjab) also known as 8
th
day disease.
Environmental factors:
Its occurrence depends upon mans physical and ecological surroundings, soil,
agricultural and animal hurbandry.

Mode Of Transmission:
By contamination of wounds with tetanus spores.
The usual portal of entry are traumatic wounds, surgical wounds,
subcutaneous injection sites, burns, skin ulcers, infected umbilicus cords and
otitis media with perforation of the tympanic membrane.
Incubation period: Usually 6-10 days but it may be short 1 day as long as
several months.
Types:
Local tetanus: In which patient have persistant contraction of muscles only at
the site of wound. The contraction may persist for many weeks. Local
tetanus is generally milder, only about 1% of cases are fatal, but may proceeds
the onset of generalizes tetanus.

Cephalic tetanus: Occurring with otitis media in which clostridium tetani is
present in the flora of the middle ear. There is involvement of the cranial
nerves especially in the facial area.

Generalized tetanus: It is the most common type of tetanus, representing
about 80% of cases. The generalized form usually presents with a descending
pattern. The 1
st
sign is trismus or lock jaw followed by stiffness of the neck ,
difficulty in swallowing and rigidity of abdominal muscles.
Other symptoms include elevated temperature, sweating, elevated BP and
episodic rapid heart rate. Spasm may occur frequently and lasts for several
minutes. Spasm continues for 3-4 wks and complete recovery may take
months.
Neonatal tetanus: It is a form of generalized tetanus that occurs in new born
infants. It occurs in infants who have not acquired passive immunity, because
the mother has never been immunized. It usually occurs through infection of
unhealed umbilical stump, especially when the stump is cut with a non-sterile
instrument.
Neonatal tetanus is common in many developing countries as responsible for
14% of all neonatal deaths but its is very rare in developed countries.

Symptoms:
Muscular rigidity and spasm.
In generalized tetanus the initial complaints may include irritability, muscle
cramp, weakness difficulty in swallowing.
Facial muscles are affected first Trismus or lock jaw is most common. This
condition results from spasm of the jaw muscles that are responsible for
chewing. A Sardonic Smile (medially).
Muscular spasm are progressive and may include a characteristic arching of
the back known as Opisthotonus. Muscle spasm may be intense enough to
break the bone.
Severe cases can involve the spasm of vocal cord or muscles involved in
breathing.
In cephalic tetanus 2/3
rd
of these cases develop generalized tetanus.
In localized tetanus muscle spasms occur at or near the site of injury. This
condition is rarely progress to generalized tetanus.
Neonatal tetanus is identical to generalized tetanus except that it affects the
newborn infant. Baby may be irritable and have poor sucking ability or
difficulty in swallowing.

Complications:
Airway obstruction.
Respiratory arrest.
Heart failure.
Pneumonia.
Fracture.
Brain damage due to lack of O2 during spasm.

Control and Treatment:
Early diagnosis:
Done may be by clinical features.
Isolation and primary care:
The patient is kept relatively in dark room.

Treatment:
The wound must be cleaned.
Dead and infected tissues should be removed surgically, wound should be kept
in aerobic condition.
Human tetanus immunoglobulin.
Diazepam total 40-200mg in divided doses.
Bed rest with a non-stimulating environment. (dim light, reduced noise and
stable temperature). Severe cases will require admission in ICU.
Respiratory support with oxygen, endotracheal tube and mechanical
ventilation may be necessary.
Human tetanus Ig is from 1500-6000 IU.
1
st
injection on being diagnosed a pregnant and other on 1-2 months gap or
may be three months before the delivery and at the time of delivery.

Prevention:
Tetanus can be prevented by vaccine. Tetanus
vaccine offered routinely to infant in combination with Diptheria and Pertusis
vaccine as a DPT-vaccine.
According to national schedule, the primary course of immunization consists
of 3 doses of DPT at the interval of 4 wks, starting at 6-weeks of age, followed
by booster at 18-months and the second booster at 5-6 years of age and a 3
rd

booster after 10 years of age.
dose of vaccine is 750 IU (1/10,000)Adrenaline intra-muscularly and
Hydrocortisone (100 mg) IU to prevent bronchospasm.

NON COMMUNICABLE DISEASES

It refers to the diseases, which cannot transfer from one person to another
person, but may transfer genetically from one generation to next generation.

Hypertension:
Hypertension, most commonly referred to as "high blood pressure", is a medical
condition in which the blood pressure is chronically elevated.
Hypertension is one of the most common worldwide diseases affecting humans.
Because of the associated morbidity and mortality and the cost to society,
hypertension is an important public health challenge.

Epidemiology:
Hypertension is the most important modifiable risk factor for coronary heart
disease (the leading cause of death in North America), stroke (the third leading
cause), congestive heart failure, end-stage renal disease, and peripheral vascular
disease.
Therefore, health care professionals must not only identify and treat patients with
hypertension but also promote a healthy lifestyle and preventive strategies to
decrease the prevalence of hypertension in the general population.

Age: A progressive rise in blood pressure with increasing age is observed, the
incidence of hypertension appeared to increase approximately 5% for each 10-
year interval of age. Age-related hypertension appears to be predominantly
systolic rather than diastolic. The systolic blood pressure rises into the eighth or
ninth decade, while the diastolic blood pressure remains constant or declines
after age 40 years.
Sex: The prevalence of hypertension was reported as 50% for white men and 55%
for white women aged 70 years or older.

Risk Factors:
Non Modifiable Modifiable
Age
Sex
Family history
Genetic factor
Ethnicity
Cigarette smoking
High salt intake
Elevated serum cholesterol
Obesity, OCP
Sedentary habits
Stress, Diet and alcohol
Diet low in antioxidants
Socio economic status

Prevention:
Primary prevention:
It has been defined as all measures to reduce the incidence of disease in a
population by reducing the risk of onset. This includes
i. Nutrition: Dietary changes are of paramount importance, such as reduction of
salt intake, moderate fat intake, avoidance of a high alcohol intake.
ii. Weight reduction: The prevention and correction of obesity is a prudent way
of reducing the risk of hypertension.
iii. Exercise promotion: Regular physical activity should be encouraged to reduce
the risk of hypertension.
iv. Behavioral changes: Reduction of stress and smoking, modification of
personal life style
v. Health education.

Secondary prevention:
i. Early case detection: Early detection is a major problem. This is because high
blood pressure rarely causes symptoms until organic damaged has already
occurred. The only effective method of diagnosis of hypertension is to screen the
population. It is emphasized that screening should not be initiated if the health
resources for treatment and follow up are not adequate.
Treatment: The aim treatment should be obtain, blood pressure below 140/90,
and ideally a blood pressure 120/80. Control of hypertension has been shown to
reduce the incidence of stroke and other complications. This is a major reason for
identifying and treating asymptomatic hypertension.

Stroke:
A stroke is the sudden death of brain cells due to lack of blood supply.
Blood flow to the brain can be disrupted either by a blockage or rupture of an
artery to the brain.
A stroke is also referred to as a cerebrovascular accident (CVA).
A stroke is an interruption of the blood supply to any part of the brain. A stroke is
sometimes called a "brain attack."

Causes of Stroke:
Blockage of artery
Clogging of arteries within the brain
Hardening of the arteries leading to the brain, e.g, carotid artery occlusion.
Embolism to the brain from the heart or an artery
Rupture of an artery (hemorrhage)
Cerebral hemorrhage
Subarachnoid hemorrhage

Clinical features:
Weakness or paralysis of an arm, leg, side of the face, or any part of the body
Numbness, tingling, decreased sensation
Vision changes
Slurred speech, inability to speak or understand speech, difficulty in reading or
writing
Swallowing difficulties
Loss of memory
Loss of balance or coordination, Vertigo
Personality changes, Mood changes (depression, apathy)
Drowsiness, lethargy, or loss of consciousness
Uncontrollable eye movements or eyelid drooping

Diagnosis:
Head CT or head MRI - used to determine if the stroke was caused by bleeding or
other lesions and to define the location and extent of the stroke.
ECG (electrocardiogram) - used to diagnose underlying heart disorders.
Echocardiogram To exclude emboli
Carotid duplex To exclude carotid artery stenosis.
Heart monitor -to determine if a arrhythmia may be responsible for stroke.
Cerebral angiography- to identify the blood vessel responsible for the stroke.
Mainly used if surgery is being considered.
Blood tests- to exclude abnormal clotting of the blood that can lead to clot
formation.

Treatment:
Immediate:
Thrombolytic drugs
Anti-platelets such as heparin. Aspirin may also be used.
Other medications may be needed to control associated symptoms. Pain killers
may be needed to control severe headache. Anti-hypertensive drugs to control
high blood pressure.
Nutrients and fluids may be necessary, especially if the person has swallowing
difficulties and may be given intravenous (IV) or a feeding tube. Swallowing
difficulties may be temporary or permanent.
For hemorrhagic stroke, surgery is often required to remove blood clots from the
brain and to repair damaged blood vessels

Long term:
The goal of long-term treatment is to recover as much function as possible and
prevent future strokes. Depending on the symptoms, rehabilitation includes
speech therapy, occupational therapy, and physical therapy. The recovery time
differs from person to person.
Certain therapies, such as repositioning and range-of-motion exercises, are
intended to prevent complications related to stroke, like infections and bed sores.
People should stay active within their physical limitations. Sometimes, urinary
catheterization or bladder/bowel control programs may be needed to control
incontinence.

Prevention:
Prevention is an important public health concern.
The most important modifiable risk factors for stroke are high blood pressure,
other include high blood cholesterol levels, diabetes, cigarette smoking, heavy
alcohol consumption and drug use, lack of physical activity, obesity and unhealthy
diet.
So control of blood pressure, blood cholesterol and blood sugar level, avoiding
smoking and alcohol, weight reduction and healthy diet helps in the prevention
of stroke.
Conversely, aspirin prevents against first stroke in patients who have suffered a
myocardial infarction.

Accidents:
It is an event that is unexpexted, unintended, unforetoldm unforeseen and that
may result in injury to a person or death of person or damage to property
Ac cident may cause: Motality, Morbidity, disability, Economical loss.
Accident is third leading cause of death (1
st
is IHD and 2
nd
is Cancer)
Types of Accidents:
1. Traffic accidents
2. Industrial accidents
3. Occupational accidents
4. Home or domestic accidents
5. Miscellaneous

Causes of Traffic Accidents:
Overloading, over speeding, overtaking, mechanical fault, failure to follow traffic
rules and laws, drunken driving, bad roads, over fatigue of driver, mental
disturbance, sudden heart attack, poor light on roads, poor vision.

Causes of Industrial accidents:
Injuries due to machine handling, eye injuries due to welding, entrapment in
elevators leading to suffocation, chemical-poison which enter body, poor light
conditions, over work,

Causes of Occupational Accidents:
In case of doctors, nurses and dispensers, there may be a quick prick in case of
hepatitis and AIDS patients.
In agricultural worker, there may be poisoning case due to handling of
insecticides.

Causes of home or domestic accidents:
a) Child accidents: swallowing of coins and foreign bodies, misuse of drug of
parents may lead to poisoning, playing with match boxes, suffocation &
choking in children, intake of kerosene oil.
b) Other domestic accidents: burning of kitchen stove, CO poisoning in the
winter season, burn due to fireworks, falling from roofs, biting by pet,
injuries due to sharp circuiting, electric shock

Miscellaneous Accidents:
a) Collapse of building where substandard material is used, collapse of very
old building, railways accidents, air crashes, drowning at beach, fall while
kiting.

Primary Factors in Prevention of Accidents:
Accidents dont just happen; they are caused. Accidents may be prevented by :
1. Data collection
2. Safety education:
- Must begin with school children
- Drivers license
- Young people training
- First aid training to drivers.

3. Promotion of safety measures:
- Safety belts and helmets, leather clothing & boots, child locks, children on
rear seats.

4. Primary care:
- Planning organization and management of trauma, emergency care services
should begin at the site of accident, continue during transportation and
conclude in hospital emergency room.

5. Elimination of causative factors:
- Improvement of roads, imposition of speed limit, marking of danger points,
reduction of electric voltage, provision of fire-guards, safe storage of drugs
and weapons.

6. Enforcement of Laws:
- Legislation plays a vital role in prevention of accidents, driving tests,
roadside breath testing for alcohol, enforcement of speed limits, inspection
of vehicles, implementation of factory and industrial laws.

7. Rehabilitation :
- Medical rehabilitation, social rehabilitation, occupational rehabilitation.

8. Research

Blindness:
Visual acuity of less than 3/60 or its equivalent or inability to count fingers in
daylight at a distance of 3 meters.
180 million people worldwide are visually disable.

Causes:
Developing countries: cataract, trachoma, malnutrition (vit A deficiency), corneal
opacity, glaucoma, congenital disorders, DM, HTN, Accidents
Developed Countries: Accidents, glaucoma, diabetes, cataract, congenital disorder

Prevention:
The concept of avoidable blindness is gaining popularity,
a) Primary Eye Care:
- Role of primary health care worker is important.
- Provide topical tetracyclines, Vitamin A capsules, Eye bandages and shields,
- Provision of Adequate nutrition.
- Periodic eye examination.
- Train LHW to promote personal hygiene, sanitation, good dietary habits
and safety.

b) Secondary Eye Care:
- Definitive management of BHU, RHC, THQ and Mobile Eye Camps.

c) Teritary Eye Care:
- At teaching hospitals where surgical intervention is done.

d) Specific Programmes:
- Trachoma control, School eye health services. Vitamin A prophylaxis (with
polio vaccine), Occupational eye health services.

Prevention of Diabetes Mellitus:
a) Screening for diabetes:
- Urine test for glucose
- Blood sugar testing
- Fasting
- Random
- 2-hour after 75g oral glucose.

b) Primary Prevention: (has no role in IDDM)
- Population strategy: Emphasis must be given on primordial prevention,
maintenance of normal body weight, elimination of risk factors.
- High-Risk Strategy(Population at risk for NIDDM): living in sedentary life,
obese, high alcohol consumers, oral contraceptive users.

c) Secondary Prevention:
- Treatment is based on: diet alone, diet and oral antidiabetic drugs, diet and
insulin.
- Taking care of:
Percentage of glycosylated Hb: 6 monthly
Self care by adhering to diet and drug regimens
Home blood glucose monitoring
Routine check up of blood pressure, visual acuity and weight.

d) Tertiary Prevention:
- Esatablisment of diabetic clinics
- Epidemiological research
- Establish national registries for diabetics.

OBESITY:
A body mass index (BMI) of 30 or more in males and 28.6 or more in females
indicates obesity.
Obesity is most prevalent form of malnutrition.

Prevention:
It should begin in early childhood.
a) Dietary changes:
- Avoid over eating
- Avoid simple CHO and Fats
- Avoid refined foods and sweets
- Increase use of fiber food.

b) Increase physical activity:
c) Others: surgical treatment (gastric by-pass, gastroplasty, jaw-wiring, Health
education)

Prevention of Snake Bite:
- Wearing knee high boots.
- Torches should be used at night in snake infested areas.
- The residential areas must be kept clean and surveyed for holes.
- During military or scouts camping, they must be advised to examine their
boots, beddings and sleeping bags.
- Stay out of tall grass.
- Be alert during climbing rocks.
- Leave snakes alone.
- Mass public education in first aid management of snake bite.
- Antivenin must be made available in health centers where large cases of
snake bite present.

============================================================================
Section 8 (Community Medicine) of ALL in ONE for the PMDC Step 1 Preparation
by Faizan Ali & Ghulam Mohiudin
============================================================================

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SECTION 8: COMMUNITY MEDICINE

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